EAP Registration Form

4 Calgary locations

 403.263.5543   1.888.655.5495 

Registered Psychologist

Couples Counselling

Counselling Calgary

Coping with Change

Chronic Conditions

Anger Management

Stress Management

Self-Confidence

Clinical Hypnosis

Communication

Calgary Alberta

Relationships

Couple Therapy
Mental Health

Introversion

Addictions

Career
Sports Psychology

Meditation Coaching

1. CLIENT DETAILS

 

Name

Contact Name

Primary Address  

Type of business

 

2. CONTACT DETAILS

 

Key contact

Title

Telephone

Fax

Email

Emergency contact name

(if different from above)

Out of hours contact number
(in emergencies)

 

3.     LIVES AND FEES

 

Commencement Date

Number of eligible households (employees)

Level of Cover

 

Option 1 (Full Telephone)

Option 2 (Full telephone plus legal & Financial)

Option 3 (Full telephone plus 6 face to face sessions)

Fee per household per annum (ex VAT)

How many employees

How many locations

Additional Comments/Special Instructions 

Share this page