EFAP Online Service Request

Service Request Form

Use this form to submit a service request.
FSEAP professional and confidential employee/member and family assistance and support services are available to eligible employees/members and their immediate family members. Please answer the following questions to initiate your service request. No personal or identifiable information is shared with your organization or others without your consent.

Please note: Your benefit may not include all of the services described. Gain more information from your benefits material or by contacting your Human Resources/Benefits department.

Not all situations are suited to our online service request process. For that reason, we assess for situations that may require a more urgent response and a telephonic assessment to better understand your current needs.
Do you believe there is a risk of harm to you or anyone else at this time?*

No, there is no risk.Yes, there is risk.
Please confirm your answer. You have indicated there is a risk of harm or violence to yourself or others at this time, is that correct?*

No, there is no risk.Yes, there is risk.
Attention

Given that you have responded "yes" to the risk of harm question, please call your local emergency or our toll-free number at 1-800-667-0993; 24 hours a day, a representative will connect you to the immediate support you require.

Return to myfseap.ca

Personal Information

Please provide the information requested below.
Company providing EAP (Employee Assistance Program) Benefit (no acronyms please)*
Your Name*

First NameLast Name
Date of Birth (MM-DD-YYYY)*

MonthDayYear
Date
Gender
Eligibility Type*

I am an employee of the company providing the benefit.I am a partner/spouse of the employee.I am a dependent child of the employee.Other
Name of Employee*

First NameLast Name
This service is for:*

Preferred Language*

EnglishFrenchOther
Does FSEAP have permission to email you? (By checking "yes", I hereby provide permission for FSEAP to send electronic information to the email address indicated and affirm my understanding that information in an email may not be secure.) Please note: by checking "yes" you will receive an email confirming receipt of your service request submission.*

YesNo
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Phone Type*
It is okay to leave a message?*

YesNo
Alternate Phone Number
Please enter a valid phone number.
Phone Type
It is okay to leave a message on alternate phone number?

YesNo

Service Request Form