EAP Intake Forms


Please Note:

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For more information about our security policies please contact us.

NoticeDo not close your browser or leave this form prior to completing all three steps.
Your information is only saved at the end of this form when you click "Submit My Information".


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Client Name
Address
For contact purposes only
Emergency Contacts
Primary Contact
Secondary Contact
EAP Information
Please tell us if you are the employee at this company or your relationship with an employee.
Employee Name
If you are not the employee please provide their name.

EAP Benefit: Your employer has contracted with The Center for Human Potential to provide counseling to its employees. This contract has been negotiated with your company's Human Resources department and entitles you and members of your family to five sessions per calendar year free of charge.  Please take a moment to speak with your counselor during your first meeting to learn about how we can best meet your needs.  If more than five sessions is necessary, there are several options for continuing treatment beyond that initial benefit including the possibility of continuing treatment at the Center or referral elsewhere.

We are committed to providing you with the best possible care.  If you are unhappy with the services we provide for any reason, please do not hesitate to contact the EAP liaison for the Center. 

After your first meeting, please take a few minutes to complete a patient satisfaction survey as your feedback is important to us.

NoticeNOTICE OF CONFIDENTIALITY: No personal information about your visit is ever reported back to your 
employer. Please discuss any questions you have about limits of confidentiality with your counselor.