EAP Intake Form | Adrienne Meryl, LCSW

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EAP Intake Form
All fields are required.
For Headspace your authorization is the email you received, and your sessions are valid for 90 days from the date you received the email. For Compsych, Optum and Aetna, you will need to call them for the authorization letter if you haven't received one yet.
Please also check your authorization for whether it covers video or office sessions or both and choose accordingly.

First Name

Last Name

Email

Phone

Birthday

Select a Service

EAP Program

Authorization #

# of Authorized Sessions

Effective Date

Expiration Date

Goals for treatment:

Thanks! We will reach out to schedule your first appointment!

Adrienne Meryl, LCSW

adrienne@uniquecounselingsolutions.com

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