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REQUEST A QUOTE

Let's "Be Better" together! Tell us a little about your needs, and we'll be in touch shortly.
Please note: This form is intended for administrative and sales‑related requests only.
Do not use this form for any clinical support requests or to submit personal health information (PHI).

Internet communication is not checked on evenings, weekends, federal holidays, or states of emergency requiring business closure. For immediate assistance, please call 800-968-8143.
Please select one:
BROKER INFORMATION
Organization
Name
Address

Street Address

Street Address Line 2

CityState

ZIP Code
Phone Number
Example: (123) 123-4567Format: (000) 000-0000.
Email
YOUR CLIENT'S CONTACT INFORMATION
Client's Organization
Client's Name
Client's Title
Client's Phone Number
Example: (123) 123-4567Format: (000) 000-0000.
Client's Address

Street Address

Street Address Line 2

CityState

ZIP Code
Client's Website Address
Client's Health Care Provider
Average Number of Employees
Does the organization have an EAP?
Client's State Locations
EMPLOYER'S INFORMATION
Your Organization
Contact's Name
Contact's Title
Contact's Phone Number
Example: (123) 123-4567Format: (000) 000-0000.
Contact's Address

Street Address

Street Address Line 2

CityState

ZIP Code
Contact's Email
Website Address
Health Care Provider
Organization's State Locations
Average Number of Employees
Broker's Name — if working with one.
Does your organization have an EAP?
Broker's Email
example@example.com
PROPOSAL DETAILS
Basic Plan — Ideal for budget-conscious employers. Includes core program support for employees and managment, plus unlimited access to the Well-Being Center.
Full-Service EAP — Built for small businesses that need enterprise-level impact on a value-driven budget. All plans also receive unlimited workplace consultations and unlimited access to our Well-being Center. Choose all that apply.

Other
À La Carte Services — One-time service agreement. Use when your organization is growing, issues arise, or you don't have an EAP. Choose all that apply.
Special Services — Please call us at 800-968-8143 to discuss your crisis needs.
Training and Development

We offer lunch-and-learn, workplace and leadership training.

Please view our offerings and specials!
Desired Start Date

MonthDayYear
Date
Date Proposal Needed

MonthDayYear
Date
How did you find out about us?
Please list any concerns with your current vendor or reason for seeking an EAP.
Type in a question.
Please be aware that electronic communication via the internet cannot be guaranteed to be completely free from potential breaches of privacy and confidentiality. If security is a concern for you, please call us at 800-968-8143.
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