Eap Scanner - Mind Wellness Center

Personal Information

Name of Your Employer *

Your Legal Name *

Date of Birth *

Email Address *

Phone Number *

- -

Home Address *

Please upload a picture of your employee ID card (if issued by employer) jpg, png, or pdf files only

⬆ Choose File

Safety Information

Do you have previous or current involvement with Adult or Child Protective Services? *

Yes No

Have you attempted suicide in the past year? *

Yes No

In the past year, have you: had a psychiatric hospitalization; been admitted to an IOP or PHP; or been to the emergency department for mental health reasons? *

Yes No

Please fax the hospital intake and discharge records to MindWell's secure fax at 607-241-9972, to the attention of EAP Services. Appointments cannot be scheduled until records have been reviewed. *

Acknowledged. I will fax records to MindWell's HIPAA-compliant secure fax at 607-241-9972.

Terms & Conditions

This form is secure and HIPAA-compliant. Your information is protected and used solely for the purpose of scheduling care.

MindWell's Practice Policies: https://www.mindwellcenter.com/practicepolicies

MindWell's Terms of Use: https://www.mindwellcenter.com/termsofuse

MindWell's Privacy Policy: https://www.mindwellcenter.com/privacy

SMS Consent

By submitting, you agree to receive text messages at the provided number from MindWell Psychology. Message frequency varies, and standard message and data rates may apply. You have the right to OPT-OUT receiving messages at any time. For assistance with managing SMS communications, reply HELP. To OPT-OUT, reply "STOP" to any text message you receive from us.

I accept the Terms and Conditions. *

✓

Thank you!

Your EAP intake has been submitted successfully. A member of the MindWell EAP Services team will contact you within 1-2 business days to discuss next steps and schedule your first appointment.

Login for Employees
in New York and Vermont

EAP Services

Personal Information

Reason for Services

Safety Information

Appointment Preferences

Terms & Conditions

Thank you!

Login for Employees in New York and Vermont

EAP Services

Personal Information

Reason for Services

Safety Information

Appointment Preferences

Terms & Conditions

Thank you!

Login for Employees
in New York and Vermont