Triad EAP

* First Name

* Last Name

Date of Birth

Job Title / Role

* Company (Customer)

Are you an employee of this company?
Yes No

If requesting counseling, will anyone else join you? Yes No

Email Address

Phone

IMPORTANT! By providing your email address or phone number, you authorize Triad to contact you by email/phone call/text message, which are not secure or encrypted. If you do not wish to be contacted through these methods, please call us at 877-679-1100.

Your Address (not company)

City

State

Zip

How can we help?

Emergency Contact Information

First Name

Last Name

Phone Number

Relationship To Employee

We will make our best effort to respond in a timely fashion from 8 AM - 6 PM MST Monday to Friday. If you or someone you know is in crisis, please call 911, go to the nearest emergency room, call 1-877-679-1100 to reach our 24-hour call center, or text "TALK" to 38255 at the Colorado Crisis Services Text Line.

*I have read and understand the above

Your information is kept secure and confidential.

Employee Inquiry