I am an individual seeking services. First Name* Last Name* Date of Birth* MM slash DD slash YYYY Gender* Male Female Additional NamesPlease complete this field if additional people may be attending counseling sessions with you. Additional dates of birth and gendersPlease 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*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed 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 MAZZITI & SULLIVAN 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 - OPTIONAL 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 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 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 [email protected] 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.CAPTCHA
