Comprehensive EAP

To schedule an appointment or request services, please complete the following form or call us at 1-800-344-1011.

Name
Address
City	State	Zip
Company
Are you an employee? Yes No
Are you a family member of employee? Yes No
If family member please provide: Employee's name
If family member please provide: Your relationship to employee
Date of birth
Service request:

Location of services desired:
Near your work (please provide location)
Near your home (please provide location)
At work (where available)
Other (please describe)

Contact instructions You may contact me by (please check all options that apply)
At home (Phone number)
At work (Phone number) Ext.
E-mail