Request Form

Who are you?

I am an/a
Employee
HR Manager / Plan Administrator / Employer
Consultant
Service Provider

Are you covered by an Employee & Family Assistance Program?

Yes
No

What can we do for you?

I would like to schedule for counselling.
I have questions on services.
I have questions on eligibility.
I have other questions.

Comments:

Please tell us a little more about yourself.

Company name: *
First name: *
Last name: *
Email: *

Phone: Ext
Preferred time for calls: Select a time zone. Pacific Time Mountain Time Central Time Eastern Time Atlantic Time Newfoundland Time

Is it okay to leave voice messages? Yes
No

City: *
Province/State: *