Additional Referral Categories:

(Your company may not have access to all of the categories below.)
For additional assistance and resources, call 404-352-8137 or 800-537-2153 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: Couselor:

Location Department:

EMPLOYEE INFORMATION

Employee Name:

Caller: (if different)

Employee Address:

City:

State:

Zip:

Home Phone: Work Phone:

Cell Phone: E-mail:

TYPE OF CARE REQUESTED

Nature of Request/Comments: