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Signature is required

Details

Last Name

First Name

Gender

Date of Birth

Phone Number Home

Phone Number Cell

Primary Email

Home Address: Address 1

Home Address: Address 2

City/Town

State

ZIP/Postal Code

Reason for Request

Service

When are you available (time of day) for your EAP sessions?

What are you seeking counseling for?

Employment Information (Your information is confidential and will not be shared with your employer)

Organization

Caller's Relationship to Employee

For Septa Employees Only

Employment Type

Length of Employment

Workplace Outcome Suite (The Workplace Outcome Suite (WOS) is a brief, psychometrically robust tool that clearly documents the impact of your EAP workplace intervention.)

How many hours of work did you miss in the past 30 days?

My personal problems kept me from concentrating on my work.

I am often eager to get to the work site to start the day.

So far, my life seems to be going very well.

I dread going to work.

In utilizing this inquiry form, I hereby agree to accept a response via email or phone using my contact information in this form. I understand that email is not always secure.

I understand that submitting an inquiry does NOT create a client-provider relationship.

I understand that if I am experiencing a physical or behavioral health emergency, I should not submit this form. Instead I should call 911 or go to my nearest hospital. And, I should call 988 promptly if I am suicidal or having thoughts of harming myself.

Please answer all questions then click on "Submit". An intake associate will contact you by the following business day to assist you with scheduling an appointment and to answer any questions.

Submit

Penn Medicine EAP Online Intake Form

How long does counseling take? - Your employer has offered a limited number of EAP Counseling Sessions at no cost to you. We offer counseling in person and via TeleHealth.

Would you like to schedule a session with an EAP Counselor? - Complete this online intake form. One of our EAP team members will call you back to schedule an appointment.