Please note that while the employer has agreed to pay for sessions as part of the Employee Assistance Program, this is a confidential service and no information will be provided to your employer, including information that you accessed the EAP or attended appointments, without your prior written consent.

Is your Employer part of Evolve Wellbeing Psychology's EAP?

Yes

No

Unsure

Number of sessions employer makes available per year

3

5

Other

Unsure

Client's Name *

First Name

Last Name

Is the client an employee or immediate family member of an employee? *

Employee

Immediate Family Member

If Immediate Family Member, has the employer included Immediate Family Members in the EAP?

Yes

No

Unsure

Is the client a minor?

Yes

No

Is the Client also interested in/in need of assessment in addition to therapy?

Yes

No

If the client is a minor, contact persons name

First Name

Last Name

Home Phone

(###)

###

####

Mobile Phone *

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Your available days for appointments

Monday

Tuesday

Wednesday

Thursday

Friday

Your available times for appointments

Early Mornings

Morning

Afternoon

Evening

Other

Are you flexible?

Yes

No