Employee Assistance Therapy Consent Form
Please complete this form to provide your consent and basic information for participation in the Employee Assistance Therapy program.
Full Name
*
First Name
Last Name
Work Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Department
Supervisor's Name
Type of Assistance Requested
*
Please Select
Counseling
Coaching
Stress Management
Other
Briefly describe the reason for seeking assistance
Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: