To be completed by the client
Client Name             Employee Name        
Address             Employer        
            Employer Location        
Client D.O.B             Employee D.O.B.      
Client SS #         Employee SS #        
Relationship to Employee             Work Phone        
Home Phone              Alt. Number        
May we contact you and leave a message at the listed phone numbers?________________________________
Referral Source:                    
    Self   Supervisor   Family   Other  
                         
Current Living Arrangements:
 
  Alone   Resides w/    Single Parent    Other    
Significant Other w/ Child
Marital Status:
   
  Married/ Sig. Other   Seperated   Divorced   Single   Widowed
Occupation:             Length of Employment:
(If family member, skip)
  Sup./ Manager   0-1 yr   16-20 yrs
  Hourly   1-5 yrs   20+ yrs
  Salaried   6-10 yrs   N/A
  Other  _________________________   11-15 yrs
How did you hear about the EAP? Sex:
  Family member   Flyer   Female
  Orientation   Brown Bag   Male
  Brochure   Other  ______________________
  Poster
Education: Age
  Less than 12   Business Technical   0-10   31-44
  H.S. Graduate   Bachelor Degree   11-20   45-54
  Some College   Advanced Degree   21-30   55+
Stueker & Associates
Phone: (800) 799-9327
Fax: (502) 452-1529