Employee Assistance Program

Client Name(Required)
Please enter your name here.
Subscriber Name
Enter the person who has the EAP benefit here (if different from above. If it is the same, you may leave blank.)
Please enter the number of sessions your EAP has approved you to have here.
This is the number you will get from your EAP that allows us to bill for your covered sessions.
This is the earliest you can have a session covered by your EAP
MM slash DD slash YYYY
This is when your EAP benefits will expire, the last date you can have a covered session.
MM slash DD slash YYYY
Please also bring any forms or paperwork from your EAP to your first session. If you have any questions or are missing any of the information we need above, please contact us at 570-521-4637!
Consent(Required)
Consent(Required)
MM slash DD slash YYYY
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