Request A Counsellor Form | Walmsley EFAP | Canadian EFAP Benefits

Request a Counsellor

First Name*

Last Name*

Birthdate*

Street Address*

Address Line 2

City*

State/Province/Region*

Zip/Postal Code*

Country*

Home Phone

Work Phone

Mobile Phone

Ok To Leave Message

Email

Best Time to Contact You

My Employer (If covered by work EAP)

Counsellor Preference (If any)

Reason for seeing a Counsellor (to help match with a counsellor)