EAP Intake Forms | Center for Human Potential

Please Note:

Secure

All information from this form will be sent over a secure connection.
For more information about our security policies please contact us.

Notice Do 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".

Progess Bar

Client Name

First Name *

Middle Name

Last Name *

Address

Street 1 *

Street 2

City *

State *

Zip Code *

Primary Phone *

Okay to leave a message? *

Yes

Secondary Phone

Okay to leave a message?

Yes

For contact purposes only

Date of Birth *

Month

Day

Year

Gender *

Male

Female

Emergency Contacts

Primary Contact

Relationship

First Name

Middle Name

Last Name

Phone Number

Street 1

Street 2

City

State

Zip Code

Secondary Contact

Relationship

First Name

Middle Name

Last Name

Phone Number

Street 1

Street 2

City

State

Zip Code

EAP Information

Please let us know the company you work for

Client Is

Employee

Spouse/Domestic Partner

Child of Employee

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.

First Name

Middle Name

Last 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.

Notice NOTICE 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.

Leave this field blank