Child Care Intake Form

Please complete the form below and a Referral Specialist
will be contacting you with more information concerning your request within 24-48hrs.
For additional assistance and resources, call 404-352-8137 or 800-537-2153to speak to a work/life specialist.

EAP or Company: Couselor:

Location Department:


EMPLOYEE INFORMATION

Employee Name:

Caller: (if different)

Employee Address:

City:

State:

Zip:

Home Phone: Work Phone:

Cell Phone: E-mail:


DEPENDENT(CHILD) INFORMATION

Current Age: Gender: Male Female

Current Age: Gender: Male Female

Current Age: Gender: Male Female


TYPE OF CARE REQUESTED

Days Needed:

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Hours Needed:

Nature of Request/Comments: