Contact Information
(*required)

Please enter your name: * Company name: * Telephone number: * Fax number:

Email address: * Mailing address: *

Organization Information:

Please list the cities / states where your company has employees, and the number of employees at each location:




What is the total number of employees in your organization?



Number of full time employees:



Number of part time employees:



Do you currently have an EAP?

Yes No

If yes, who is your EAP provider?



Are your employees offered telephone counseling?

Yes No

How many face-to-face therapy sessions are provided?



Does your EAP offer any consulting/coaching services for your management team?

Yes No


Health Plan Information:

Is your company self-insured?

Yes No

Who provides the employee health plan(s) for your company?

Plan A:



Plan B:



Plan C:



How many mental health counseling sessions do members receive under each plan?

Plan A:



Plan B:



Plan C:



What is the deductible amount for each plan?

Plan A:



Plan B:



Plan C: