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Employee Assistance Program EAP if applicable Do you have employee assistance program benefits through your employer Yes No If yes what is the name of the EAP provider Authorized Sessions Authorization Number Authorization Start Date / / Please Note You must bring a copy of the EAP Provider s authorization letter to your first session. EAP Providers can also fax a copy of the authorization to us at 801-446-6511. If yes please indicate the family member s relationship to you in the space...
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