EAP Registration Form

Register Your Business for EAP

EAP Registration Form
Full Name*

First NameLast Name
Phone Number*
Phone number of best contact in the business registering for EAP
E-mail*
Email for the best contact (either accounts or manager) for business registering for EAP program
Please List the Name of Your Business
Name of workplace / business
Please Indicate What Program You Are Interested In?
For more information - visit our website or contact info@redefinelife.com.au
Please indicate how many sessions you would offer to your staff
If you selected "Other" please include the number in the describe the challenges box further down.
Please list the accounts email address / best email for invoicing purposes
company accounts email address
How would your workplace prefer to be invoiced:
All invoices are deidentified, so no one will know who is using the service
I live in the Australian state of *
This is to help us with session times if your counsellor is in another state. Note that currently we only have in person sessions in Victoria.
How did you hear about us?*
Other
Should be Empty:

Register Your Business for EAP