One Feather / Community EAP Client Data
Form for Appointment:

 

Would you like to schedule an appointment? YES__ ___IF NO PLEASE CLICK HERE
Name:
Address:
City:
State:
Zip:
Do we have permission to contact you at the above address? YES
NO

Male
Female
Date of Birth:
Marital Status: Single
Married
Divorced
Widowed
Seperated
Ethnicity: Native/First Nations
Pacific Islander
Black
White
Hispanic
Asian
Bi-Racial
Other:
Home telephone number?
May we call you at this number? YES _ NO
May we leave a message? YES _ NO
Work telephone number?
May we call you at this number? YES _ NO
May we leave a message? YES _ NO
Other Number(s)
May we call you at this number? YES _ NO
May we leave a message? YES _ NO
When is the best time to call?
Name of Employer or Organization through which you are accessing EAP
Services?
What is your job title?
Part-time or full time employee? FULL_TIME_ PART_TIME
Are you the:

employee
spouse of an employee
child of an employee
or other?

Are you a: Self Referral
Informal / Suggested Referral
Formal / Mandated Referral
Other?
Would you prefer a morning, afternoon, or evening appointment? MORNING_ AFTERNOON EVENING WEEKEND
Would you like your appointment to be closer to your work or home address? WORK_ HOME
Can this concern be addressed by one of our credentialed telephone counselors?

YES _ NO

Is this a crisis or emergency situation?

YES__ NO
(IF YES, PLEASE CALL 911 OR CALL 1-800-905-2911 AND INFORM THE OPERATOR YOU WOULD LIKE A CALL BACK FROM ONE OF OUR 24 HOUR ON-CALL COUNSELORS)

Please note an EAP Counselor in your area will contact you within two business days to schedule an appointment at your convenience.

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