Name:
Title:
Company:
Address:
Address:
City:	State: Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware DC Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentuckuy Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York N. Carolina N. Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island S. Carolina S. Dakota Tennessee Texas Utah Vermont Virginia Washington W. Virginia Wisconsin Wyoming
Zip
Phone:	-  -   Ext:
Email:
Status:	Select One Current EAP Client Prospective EAP Client I am a Broker I am a Provider I am a Prospective Provider Not Sure   (required)
If interested in implementing an EAP, please provide the following:
Number of Locations:       Number of Employees:
Location 1: Employee Count:  Location 2: Employee Count:  Location 3: Employee Count:  Location 4: Employee Count:  Location 5: Employee Count:  Location 6: Employee Count:
Do you currently have an EAP in place?    Yes No If yes:   Name: Cost:  Utilization Rate:  Reason for change:
Does your organization offer mental health/substance abuse benefits? Yes No
Is the company a member of the Employers Group?   Yes No
Have specific Comments or questions?  Feel free to e-mail them to us!