(800) 322-9320
(406) 721-9320
Fax: (406) 549-5305

EMPLOYEE ASSISTANCE PROGRAM (EAP)

Welcome! We invite you to take a couple of seconds to fill in this questionnaire. Please note that some sections are optional.

Your name:
Job title:
Company name:
Company mailing address:
Email address:
Phone number:
Number of employees:
Would you like further information regarding an EAP through Life Care Services?	Yes No
If so, when would you like to be contacted?	January February March April May June July August September October November December 2005 2006 2007 2008
What is your preferred method of contact?	Phone Email Mail Visit
***Optional:
Does your company have an EAP?	Yes No
If so, how many counseling sessions are provided?	3 4 5 6 7 8 Other
Who qualifies for the EAP benefit?	Employees Only Employees & Spouses Employees & Spouse Equivalents Employees & All Dependents
Who is your EAP provider?
What is the EAP contract period?	January 1 - December 31 July 1 - June 30 Other

Thank you for completing these questions. For taking the time to fill out our questionnaire, we will send or deliver one of your beautiful LCS mugs. Again, thank you!