Employee Assistance Program Form

Please fill out this form completely and accurately to help us understand your situation and provide the appropriate assistance. After completion, submit this form to your HR department or directly to your EAP Coordinator for confidential processing.

EMPLOYEE INFORMATION

Field	Information
Employee Name	[Your Name]
Employee ID	[Your Employee ID]
Department	[Your Office Department]
Position	[Your Position/Role]
Contact Number	[Your Contact Number]
Email Details	[Your Email Address]

ASSISTANCE REQUEST DETAILS

Field	Information
Date of Request	[MM-DD-YYYY]
Nature of Issue	[Stress]
Brief Description of Issue	[Over fatigue]

CONSENT FOR SERVICES

• I hereby consent to participate in the Employee Assistance Program provided

by [Your Company Name]. I understand that my participation is confidential and voluntary.

Date: [MM-DD-YYYY]

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