You may use this form for two purposes:
Note: You may enter multiple client names for the same therapist. If a family member is seeing a different therapist, please complete a separate form. If you would like to change therapists, please submit the Initial Request for Services form.
Your request will be processed and you will receive confirmation via email or phone (please indicate your preference below.) Should we have any questions, we will contact you via the method you indicate to ensure accuracy in the renewal process.
Our services are 100% confidential. When you contact us, it's strictly between you and our staff - your employer will not be notified and all information you share with us will be kept in the strictest confidence. There are some limits to confidentiality. We are required by law to report suspected child or elder abuse to the proper authorities. Similarly, if we believe that someone might harm themselves or others, we are required to take appropriate action.
"No Show" or "Late Cancellation" of appointments will be counted as one of the client's authorized sessions. Please note: Providers bill Sutter EAP for sessions missed by our clients.
Items marked with * are required