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Number of Employees

Does Your Company Currently Have An EAP Program?

Yes No 

What Time Frame does Your Company Plan on Purchasing An EAP?

Two Weeks One Month Six Months 

How did you hear about Gup & Associates, Inc?

Information Requested

Descriptive literature Request for proposal Have a marketing representative contact me 

Comments/Special Requests

Are your mental health and substance abuse costs increasing faster than expected?

Yes No 

Are you interested in a consultation that will review your current behavioral costs to determine areas of improvement and potential cost savings?

Yes No 

Which of the following areas are affected by your employee's personal problems:

Added Liability Costs Tardiness & Absenteeism Lost Time/Productivity Plan Client Dissatisfaction ADA Disputes Labor Disputes Morale Workman's Compensation Added Medical Costs Turnover 

Would management want a consultation resource to resolve deteriorating employee job performance problems?

Yes No 

Are you interested in managing your mental health and substance abuse disability claims?

Yes No 

Do you need assistance with executives/professionals impaired by substance abuse?

Yes No 

Do you have to comply with Federal Department of Transportation (DOT) regulations with your drivers?

Yes No 

Please check the consulting service areas you are interested in?

EAP/Behavioral Health Executive Coaching Stress Management Prevention Violence in the Work Place Intervention Career Development & Transitions Disability Management Relationship/Team Building Sexual Harassment Critical Incident Other 

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