Family Resources Referral Form

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

EAP or Company: Emory:

Position:

ID # or Last 4 digits of SS:

EMPLOYEE INFORMATION

Employee Name:

Caller: (if different)

Employee Address:

City:

State:

Zip:

Home Phone: Work Phone:

Cell Phone: E-mail:

TYPE OF CARE REQUESTED

Search Area:

City: State: Zip:

Nature of Request/Comments:


2957 Clairmont Road | Suite 120 | Atlanta, Georgia 30329