Employee Assistance Program (EAP) Counseling Request

Employee Assistance Program (EAP) Counseling Request
This form is for individuals seeking counseling services through an employer-sponsored Employee Assistance Program (EAP).

EAP services are confidential, short-term, and require authorization through your employer or EAP administrator prior to scheduling.

Please complete this form accurately. Our intake team will verify your EAP authorization before contacting you.
Full Name*
Email Address*

Confirmation EmailConfirm Email
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Contact Method*
Evernorth Behavioral Health (Cigna EAP)Aetna Employee Assistance ProgramOther
Employer Name
EAP Administration
Employer Name*
EAP Authorization/ Case Number*
Number of Authorized Sessions*
Authorized Start Date (If known)

MonthDayYear
Date
Stress/BurnoutAnxietyDepressionWork-related stressRelationship ConcernsLife transitionsGrief/lossSubstance use concernsOther
NoYes
If you are experiencing thoughts of harming yourself or others, please seek immediate help.

Call 911, go to the nearest emergency room, or contact the Suicide & Crisis Lifeline by calling or texting 988.

This form is not monitored for emergencies.
Telehealth (Nevada residents only)In-Person- Las VegasIn-Person- PahrumpNo Preference
Upload Governmental ID*

Cancelof
Upload- EAP Authorization Letter or Confirmation

Cancelof
Upload- Insurance Card (If provided by EAP)

Cancelof
I confirm I am authorized to use EAP benefits through my employerI understand sessions are limited by my EAP planI understand services are confidential within EAP guidelinesI consent to be contacted by F.A.M Healing Center regarding this request
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