Client Intake Form

We request the following information as an easy way to refer you to a professional. All information is confidential.

"*" indicates required fields

Client Company*

Client Name*

Gender*

Name of Employee*

Date of Birth*

Phone Number*

Okay to leave a voicemail message?*

Yes

Email Address*

Health Insurance*

Home Address*

Street Address City State / Province / Region ZIP / Postal Code

Who referred you to EAPLM?*

Years working for company*

Is job affected?*

Yes

Is this mandatory to keep your job?*

Yes

In-person or virtual session?*

In-Person

Virtual

Presenting Issue*

CAPTCHA

Name

This field is for validation purposes and should be left unchanged.