Request a Referral

Welcome to First Choice Health EAP’s online referral request tool. Please fill out the information below, acknowledge EAP polices and submit your request. Once submitted, a representative will reach out to you in 2-3 days with your referral information. These referrals are monitored Monday – Friday from 8:00am-5:00pm.

If you are in crisis or need immediate support, please call us 24/7 at 1-800-777-4114.

Contact Information

First Choice Health will use this information to reach you with questions or updates. A provider will call you within 48 business hours to schedule the first appointment. If you have not heard from a provider, please call us at 1-800-777-4114.

Please note online requests are monitored Monday – Friday 8am-5pm PST. If you are experiencing a crisis or need support outside of these hours call 1-800-777-4114.

Contact & Eligibility

The Employee's Company Name

First Name (of person attending)

Last Name (of the person attending)

Please define Client relationship to Employee

If not employee, please list name of Employee

Date of Birth

Gender

**Adults 18 years and over must request services for themselves

Name of person filling out this form

Primary Phone

Leave a message (Primary)?

Secondary Phone

Leave a message (Secondary)?

You must select Yes for Leave a Message for either the primary phone or secondary phone.

Email Address For Confidential Emails

**Please note that completing this form will result in email confirmation and customer satisfaction survey. Enter “N/A” if you do not wish to receive emails.

Referral Information and Preferences

First Choice Health strives to match all client requests but cannot guarantee all requests. Please note that our criteria is to match to a counselor within 15 miles or 30 minutes with a first appointment available within two weeks. Scheduling delays may result due to specific requests, limited availability or popular timeslot requests such as evenings. If you are in crisis, please call us at 1-800-777-4114 for immediate service.

Scheduling Preferences

Morning (8am-12)

Afternoon (12-4)

Evening (4pm or later)

Flexible

Location Preference

Are you interested in telehealth?

List names, ages and relationship of other people attending sessions with primary client

**Please note – we can only discuss referral information with primary client.

Primary Health Insurance

**Leave blank if you do not wish to use insurance afterward.

Counselor Gender Preference

What general category of problem are you experiencing? (Check up to three issues that apply)

Category of Problem missing or too many checked items

(Optional) More information about the reason you are seeking EAP services can often help us choose the best provider for you

By submitting this request, you acknowledge that FCH EAP or an EAP provider will contact you to schedule an appointment. Additionally, you acknowledge that late-cancellations & no-shows count against my available sessions. You are eligible for a re-referral if requested after the first session but before scheduling a second.

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