Request Counseling Form

• First Name
• Last Name

• Phone (mobile)
• Okay to leave message:

  YesNo

• E-mail

• Street
• Apt, floor, suite, etc.

• City
• State Alabama (AL)Alaska (AK)Arizona (AZ)Arkansas (AR)California (CA)Colorado (CO)Connecticut (CT)Delaware (DE)District of Columbia (DC)Florida (FL)Georgia (GA)Hawaii (HI)Idaho (ID)Illinois (IL)Indiana (IN)Iowa (IA)Kansas (KS)Kentucky (KY)Louisiana (LA)Maine (ME)Maryland (MD)Massachusetts (MA)Michigan (MI)Minnesota (MN)Mississippi (MS)Missouri (MO)Montana (MT)Nebraska (NE)Nevada (NV)New Hampshire (NH)New Jersey (NJ)New Mexico (NM)New York (NY)North Carolina (NC)North Dakota (ND)Ohio (OH)Oklahoma (OK)Oregon (OR)Pennsylvania (PA)Rhode Island (RI)South Carolina (SC)South Dakota (SD)Tennessee (TN)Texas (TX)Utah (UT)Vermont (VT)Virginia (VA)Washington (WA)West Virginia (WV)Wisconsin (WI)Wyoming (WY)
• Zip

• Services are available to me through (Name of Organization):

• I am the:

  EmployeeSpouseDependent (18 or older)Other

• If Other, please explain:

• Date of Birth: (dd/mm/yyyy)
• Gender:

  MaleFemaleOther

• What brings you to the EAP?

  DepressionAnxietyStressRelationshipAlcoholDrugsOther

• If Other, please explain:

• Who will attend the sessions:

  Just meMe & my significant otherMe & my familyMe & my dependent(s)

• Please provide full name, date of birth and gender of all attending:

• Session Preference (check all that apply):

  In-personVideoPhone

• Please provide any additional information that may be helpful for us to know:

Current month ye@r (4 digits) day *

Leave this field empty *