Client Intake

Employer/Department:

Today's Date:

Client's Full Name, last name first please.

Client's Employee ID Number:

Relationship of client to employee?

Street Address

City

State

Zip Code

Relationship Status

How long married or divorced?

Date of Birth:

Home Phone:

Work Phone:

Cell Phone:

May we contact you by email?

Email Address

Referred by F/EAP by:

Full Name of Employee if NOT YOU:

Employee's Employee ID number:

Employee's Date of Birth

Employee's Department and date of Hire

May we make a copy of your health insurance card?

If not, your insurance member # & administrator:

How did you learn about the FEAP?

Ethnic origin

Highest Level of Education

Job Category?

Job Status?

Salary Class?

Have you used FEAP before today?

If yes, when?

Are you here today in response to a management referral?

If so, name of referring manager/supervisor:

Their phone number:

University of Virginia Health System