Request for Services Form Step 1 of 4 25% Contact InformationPlease give us a number where we can call you between the hours of 7:30 a.m. to 6:00 p.m. Monday - Friday CST.Your First Name*Your Last Name*Email Address:* Primary phone number*Primary phone type*HomeWorkCellOk to leave a message?* Yes No Alternate phone numberAlternate phone typeHomeWorkCellOk to leave a message? Yes No Best time to contact you*7:00am - 10:00am10:00am - 1:00pm1:00pm - 4:00pm4:00pm - 7:00pmWhat timezone are you in?*ESTCSTMSTPSTAre you the Employee or a Dependent?*EmployeeDependentYour relationship to the employee?*Is the person seeking help yourself or your dependent?* Myself My dependent Employee Information:Employee's First NameEmployee's Last NameEmployer Name*OccupationLength of Employment (in years) Services are being requested for the following person:You may request services for yourself or a dependent.First Name*Last Name*Address Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Date of Birth* MM slash DD slash YYYY Sex*MaleFemaleEmployment Status*FullPart TimeStudentDisabledRetiredDoesn't WorkOtherMarital Status*MarriedSingleDivorcedSeparatedWidowedCo-HabOtherPrimary Language*EnglishSpanishChineseDanishDutchFilipinoFrenchGermanGreekHindiHindi/PunjHindu/MalaHungarianItalianJapaneseJewishKoreanLatvianMultiplePersianRussianTurkishHave you ever used our services before?*YesNo Referral Source Active Health DOT Supervisory Family Formal Supervisory Friend HR Media PIP Provider Self Supervisor Other Presenting ProblemPresenting Problem*DepressionFamilyLegalAlcohol/DrugsStress/AnxietyGriefParent/ChildMarital/RelationshipsEmotional/BehaviorFinancialPharmacy ProgramThriveOtherDo you have an existing case with IEAP?*YesNoCase Number (if known):Please give a brief statement of your request/situation that will assist the Case Manager when they contact you (i.e.: statement of problem, reason for request, etc,):*A Case Manager will contact you by phone on the next business day between the hours of 7:30 am and 6:00 pm (CST). No replies will be made via e-mail. If you need to speak to someone immediately, please call 800-324-4327.Would you agree to have a satisfaction survey sent to your home?YesNoEmailThis field is for validation purposes and should be left unchanged.