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.
Employee Information:
Company/Organization you work for:*
Relationship Status:*

SelfSpouse/PartnerChildParentsOther
Preferred Referral Language

English - DefaultSpanishFrenchChineseOther
Name of Employee Assistance Program (EAP):
Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Preferred method of communication:*

PhoneEmailOther
Phone Number:*
Please enter a valid phone number.
Extension:
OK to leave message?:

YesNo
Email Address:*
example@example.com
OK to email?:

YesNo
Address:*

Street Address

Street Address Line 2

CityState / Province

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

Employee Information: