Work-Life Referral Request Form

The Life Expert Referral Form can be used to access work-life services and support. Please complete the form, including a detailed overview of your needs.

If this is an emergency, please contact your EAP provider via telephone for immediate assistance. Thank you.
Employee Information:
Company/Organization you work for:
Relationship Status:

Other
Preferred Referral Language

Other
Name of Employee Assistance Program (EAP):
**Please note: This information is necessary to connect you for services. We will not be able to assist without this provided. If you do not know your EAP program, please contact your HR department for this information.
Name:

First NameLast Name
Date of Birth:

MonthDayYear
Date
Preferred method of communication:

Other
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Extension:
OK to leave message?:
Email Address:
example@example.com
OK to email?:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Case Details:
Please provide a description of the issue(s) for which you are seeking support:
Additional comments:
Should be Empty:

Employee Information: