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Client Intake Form


Please Note: Providing demographic information is optional, but helps us to better serve you.


* denotes required field
Employee Information
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Contact Information
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Demographics
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Reason for contacting EAP
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Over the past 2 weeks, how often have you been bothered by any of the following problems?
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Work Impact
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Submit

Washington State Employee Assistance Program - (877) 313-4455 - FAX (360) 664-0498