Request A Counsellor Form | Walmsley EFAP

I am covered by my employers EFAP:

Yes

I am employee:

Yes

If Yes: what is the company name?

Employee First Name :

Employee Last Name :

Employee Date of Birth:

My First Name:

My Last Name :

I am seeking counselling for:

Myself

Spouse/Child/Other dependent

Street Address

City

Province

Postal Code

Ok to send correspondence

Yes

Landline

Ok to leave message

Yes

Cell

Ok to leave message

Yes

Work

Ext

Ok to leave message

Yes

Preferred method of contact

Phone

Text

Best time to contact:

General issue that will be addressed with the counsellor?

Additional information: