Name:

Title:

Company Name:

Locations:

Website:

Telephone Number:

E-Mail Address:*

Areas of most interest for your company (check all that apply):

 Counseling
 Management Services
 Crisis Management

Substance Abuse

Wellness / Training

Other (please specify)

# of Employees -
Full-Time / Part-Time

Full-Time

Part-Time

Projected start-up date

Do you currently have an EAP?

Yes

No

Additional comments