Penn Medicine EAP Online Intake Form
What is an EAP (Employee Assistance Program)? - EAPs serve organizations and their employees in multiple ways, ranging from consultation at the strategic level about issues with organization-wide implications to individual assistance to employees and family members experiencing personal difficulties. In general, an EAP is a set of professional services specifically designed to improve and/or maintain the productivity and healthy functioning of the workplace and to address a work organization’s particular business needs through the application of specialized knowledge and expertise about human behavior and mental health. Penn Medicine EAP is here to help you identify and resolve personal concerns, including health, marital, family, financial, alcohol, drug, legal, emotional, stress, or other personal issues that may affect job performance.
What is professional counseling? - Counseling is a collaborative effort between the counselor and client. Professional counselors help clients identify goals and potential solutions to problems which cause emotional turmoil; seek to improve communication and coping skills; strengthen self-esteem; and promote behavior change and optimal mental health.
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.
* denotes required field
Signature is required
Date of Birth
Phone Number Home
Phone Number Cell
Home Address: Address 1
Home Address: Address 2
Reason for Request
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)
Caller's Relationship to Employee
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.
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