Please complete this field if additional people may be attending counseling sessions with you.
Please include dates of birth and the gender for anyone else who may be attending sessions.
We will not mail anything to you without your permission.
Please let us know the best way to contact you.
If we have to contact you on the phone, may we leave a message?
PLEASE TELL US THE NAME OF YOUR EMPLOYER 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.
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.
THE MORE YOU CAN TELL US ABOUT YOUR SITUATION, THE BETTER WE CAN DIRECT YOU TO AN APPROPRIATE RESOURCE.
Check all that apply.
Please be as detailed as you can be. This allows us to find the best resource(s) to fit your situation.
We want to match you up with someone who will be a good "fit" for you!
THANK YOU FOR REACHING OUT TO MAZZITTI & SULLIVAN EAP SERVICES. 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 INFO@MSEAP.COM. WHILE WE STRIVE TO CONTACT PEOPLE IN THE METHOD THEY REQUEST, PLEASE NOTE THAT EVEN IF E-MAIL IS PREFERRED, WE MAY NEED TO CALL YOU. BY HITTING "SUBMIT," YOU UNDERSTAND THAT YOU ARE REQUESTING THAT MAZZITTI & SULLIVAN PROVIDE ASSISTANCE TO YOU.