DRAFT Arkansas’ Leading Local EAP Step 1 of 2 50% Client Signature(Required)Please type your signature in this box to acknowledge that you have read this form and understand its contents. Date of Signature(Required) MM slash DD slash YYYY Your Name First Last Date of Birth MM slash DD slash YYYY Your Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Preferred PhonePreferred Email You are the: Employee Family Member Retiree Education 1 - 12 Years HS Graduate Some College College Graduate Advanced Degree Other Ethnicity Caucasian African-American Hispanic Native American Asian Other Gender Male Female Other Marital Status Single Married Divorced Separated Widowed Living with Someone Employee InformationName First Last Job TitleCategory Clerical Manager / Executive Manufacturing / Operations Professional / Technical Sales / Marketing Wage Type Hourly Salary Exempt Shift First Second Third Rotating Other How did you hear about us? EAP Training Family Supervisor Co-Worker Newsletter Article Poster / Brochure Other Presenting ProblemPrevious EAP Once Twice More Emotional Depression Anxiety Stress Other Relational Marriage / Relationship Parent / Child Family Other Addiction / Abuse Alcohol Narcotics Other Work Co-Worker Supervisor Performance Other Other Legal Financial Other « Previous PostNext Post »
