Contact Name:
Title:              
Company:       
Address:         
                      
City:                State:  Zip:

Phone:            

Email:                       
Company Web site:    
Number of Employees:

Type of EAP Required (check one that applies):
Basic EAP 1-3 Assessment visits
Enhanced EAP 1 - visits
Include Worklife

Do you currently have an EAP?  Yes No

If yes, please enter the name of your EAP provider:

Please share any areas of concern with your current EAP:

When would you like to start your EAP?
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31    January February March April May June July August September October November December   2006 2007 2008 2009

Other comments or questions:

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Wellspring Family Services EAP will not share your information
or your responses with any outside source.