Service Request

* required

Employer

* Employee ID Number:

* Name of Employer:

Member Information

* Member Name:

* Member Email:

Member Phone Number:

Fax Number:

Member Address:
Zip Code:

Gender:: Male Female

Referral Type

Referral:: Employee; Dependent Name

Number of Dependents:

Dependent Name:

Dependent Date of Birth:

Dependent Relationship:: Spouse; Child; Grandchild

Insurance:

Reason for Accessing EAP

Interests:

Daycare

Personal Wellness

Car Dealership

Legal Services

Massage Therapy

Dry Cleaning Service

Other

Convenient Services

Behavioral (Type of Counseling):

Provider Preferences:

Bilingual

English

Male Female

East

West

Northeast Central

Comments:

For more information contact us at - info@suncitybehavioral.org