EAP Request Form

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EAP Request Form

This form is only for EAP request purposes. The information input is the bear minimum information we need to create a number for the individual requesting it.

EAP's can be used with any licensed counselor. We do have specific counselors that are trained to assist first responders, their spouses and their children. Firefighters, spouses, children, are able to use up to six (6) visits completely paid for by ACFD1.

EAP numbers will be given within 24 hours of the request. Take the letter to a counselor of your choosing. Counselors will receive payment within 30 days of the Peer Support Team receiving the invoice.

Once again this request is confidential. If you have any concerns please reach out to Brian Cook or Jasmine Parten, Peer Support Leads.

Select the one that fits the best. *

Firefighter

Spouse

Child

Department (Optional)

Would you like a peer support member reach out to you? *

Yes

If answered yes to previous question, please leave email or phone number and name if you fill comfortable.

Please enter an email address that would like the letter sent to. This does not have to be an email address that is used within the fire service world. If you would like your letter delivered to a station or trusted person, please input below. *

Submit

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