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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

Names and ages of anyone planning to attend EAP sessions

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.

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

Have you been to counseling before?

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

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

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

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

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)

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 you need to cancel an appointment with less than 24 hours’ notice or do not attend a scheduled appointment, one session will be deducted from your remaining covered sessions.

Counseling Preference

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

Please share your time availability for counseling appointments. Initial therapy appointments typically occur during daytime business hours. Open time availability for appointments will help you be seen sooner.

If seeking counseling, who is the identified patient’s Health Insurance carrier? 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.

I would like to use my EAP sessions for therapy with Talkspace. I understand my insurance may not be in network with Talkspace. We may call you to confirm your eligibility for sessions.

I would like to use my EAP sessions for therapy with Better Help. I understand Better Help does not accept health insurance. We may call you to confirm your eligibility for sessions.

I would like a referral to a counselor for my EAP sessions only. I understand that the counselor will not be empaneled in my health insurance plan.

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.