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About
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Contact
Employee Request for Services
Request for Services — Employees
M&S EAP
2022-09-19T23:51:01-04:00
“I am an individual seeking services.”
First Name
*
Last Name
*
Date of Birth
*
MM slash DD slash YYYY
Gender
*
Male
Female
Non-binary
Prefer not to answer
Prefer to self-describe *
* Self-described gender (if applicable)
Additional Names
Please complete this field if additional people may be attending counseling sessions with you.
Additional dates of birth and genders
Please include dates of birth and the gender for anyone else who may be attending sessions.
Address
*
We will not mail anything to you without your permission.
Street Address
City
State*
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
*
May we leave a message?
*
If we have to contact you on the phone, may we leave a detailed message?
Yes
No
Email
*
How do you prefer to be contacted?
*
Please let us know the best way to contact you.
Email
Phone
 
EMPLOYER OR GROUP SPONSORING YOUR EAP
Please tell us the name of your employer or the group sponsoring your EAP with M&S EAP so we can verify all of the EAP options available to you. Unless you sign a consent form, no information will be shared with your employer regarding your use of the Employee Assistance Program.
Employer or Sponsoring Group Name
*
Employee/Member Name
*
INSURANCE INFORMATION
Sometimes sessions go beyond what the Employee Assistance Program offers and it is billed to an insurance company. We want to make sure our recommended provider accepts your insurance, and some providers like to have this information handy if you opt to go beyond the EAP sessions.
Insurance Carrier
*
Subscriber Name
Insurance ID
Insurance Group
REFERRAL INFORMATION
The more you can tell us about your situation, the better we can direct you to an appropriate resource.
What resource can we help you with
*
Check all that apply.
Counseling
Elder Care Information & Resources
Legal Resources
Financial Resources
Health & Wellness Resources
Inpatient / Detox
Housing Resources
Other Community Resources
Other Online Resources
Can you tell us more about your situation
*
Please be as detailed as you can be. This allows us to find the best resource(s) to fit your situation.
If you would like to see a counselor, do you have any preferences?
We want to match you up with someone who will be a good "fit" for you!
What type of counseling would you prefer?
*
Virtual Counseling
Telephonic Counseling
Face to Face Counseling
THANK YOU
Thank you for reaching out to M&S EAP. When you hit submit, your information will be forwarded to someone on our team who will get in touch with you by the end of the next business day. If you need anything in the meantime, please feel free to call us at 800-543-5080 or email us at
[email protected]
. While we strive to contact people in the method they request, please note that even if email is preferred, we may need to call you. By hitting "submit," you understand that you are requesting that M&S EAP provide assistance to you.
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