EAP Organisation Intake Form

Organisation Details

Organisation Name *

Key Contact Name *

Key Contact Position

Key Contact Email *

Key Contact Phone

Organisation Address

Service Setup

Sessions Per Employee

Access Pathway

Review Period

Review Date (if applicable)

Extensions Allowed

Extension Approval Method

Billing

Billing Address

Invoice Email

Invoice Contact Name

Purchase Order Number

Sessions are invoiced after each session.

Agreement Acknowledgement

I acknowledge confidentiality terms, accept the cancellation policy and agree to invoicing terms.

I confirm I am authorised to enter this agreement

Additional Notes