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Eligibility

Who is the Employer/Union/Association providing the ESI EAP benefit?

Are you the Employee or Family Member?

Job Title Employee

Job Title Family Member

Please share the name of the employee (if not yourself)

What can we do for you?

Please tell us a little more about yourself

First Name (Legal)

Nickname/Preferred Name

Last Name

Date of birth

Sex assigned at Birth

Self-Identified Gender

Preferred Method of Contact

Type

Phone Number

Okay to Leave a Message

Email Address (Preferred) We will not sell or share your email address.

Is it okay to Communicate with you via email?

Address where you are CURRENTLY Living

City

State

ZIP/Postal Code

Work ZIP/Postal Code

Current Marital Status

Details We care about your well-being and want to ensure that you have access to the support and services you need. To help us understand how we can help, we ask that you answer a few questions about your experiences and any challenges you may be facing. If EAP requires additional information or clarification, an EAP counselor will contact you.

Please provide a brief description of the issue(s) for which you are seeking help:

Are you expected by your employer to receive EAP services

Have you been to counseling before?

Describe: (when last seen, name of current counselor if applicable)

Do you have concerns about your alcohol or substance use/misuse?

Describe: (date of most recent substance(s) used, frequency, previous treatment attended, are you experiencing withdrawal symptoms )

Do you have past or current thoughts of harming yourself? If current, go to your local hospital or call 911/988.

Describe: (date of most recent thoughts of harm or suicide, timeframe of thoughts/action, details of previous attempts, history of psychiatric hospitalization)

Do you have past or current thoughts of harming others? If current, go to your local hospital or call 911/988.

Describe: (date of most recent thoughts of harm, timeframe of thoughts/action, identified target)

Do you have past or are currently experiencing family violence? If you are in danger, call 911

Describe: (date of most recent experience, is there current court/legal involvement)

Do you have any current significant health problems?

Do you currently have any concerns related to sleep, appetite, concentration, enjoyment of life, self-care?

Have you had any recent or current changes in your life (i.e. loss, setbacks, illness)

Describe supports, community involvement, etc. that you have in your life

Additional detail (200 characters)

Provider (Mental Health Professional) Preferences Your employer has offered a limited number of EAP Counseling Sessions at no cost to you. We offer counseling in person and via TeleHealth. If EAP requires additional information or clarification, an EAP counselor will contact you.

If seeking counseling and you intend on using your insurance after your EAP sessions, list the identified patient’s Health Insurance carrier below. We will work to refer you to an in-network provider with your organization’s insurance plan in the event you choose to continue beyond EAP covered sessions.

Counseling Preference

If seeking counseling, add any desired provider characteristics Ex: male, female, LGBTQ+ expertise, African American etc. EAP will work to meet your request whenever possible.

Please share your general time availability for counseling appointments (Ex afternoons after 1pm, mornings before 12pm). Initial therapy appointments typically occur during daytime business hours. Flexible open time availability for appointments will help you be seen sooner.

If seeking counseling, who is the identified patient’s Health Insurance carrier? Be as specific as possible about the insurance plan. We will work to refer you to an in-network provider with your organization’s insurance plan in the event you choose to continue beyond EAP covered sessions.

Referral

If requesting a face to face counseling appointment, locations/travel distance preferred to an appointment:

Names and ages of anyone planning to attend EAP sessions

Submit

Online Request for Confidential EAP Services

If this is a life-threatening situation, call 911/988 or go to your local hospital or emergency department. If you are in crisis, call or text 988.

If you prefer to speak to a counselor to complete your intake or receive support, please call 1-800-252-4555. Counselors are available 24/7.