New Patient Form - EAP
Fill this out if you would like to become a new patient at Family Guidance Centers and have EAP services through your employer. It is the patient's responsibility to obtain a referral or authorization number for EAP services. You will need to call the EAP management company to obtain this. If you need an appointment before they will give you the number, please submit this form and we will contact you in 2-3 business days. If you already have the referral or authorization number, please notate it on this form, and we will contact you to schedule an appointment in 2-3 business days. If you have any further questions, please call 804-743-0960 or email us at
Please note that we currently do not have psychiatric coverage on staff.
Patient's Full Name (Last, First)
Patient's DOB (MM/DD/YYYY)
City, State, and Zip Code
Phone Number (Please include area code)
Please answer N/A if you do not currently have an email address.
Which office location are you looking for?
Chesterfield - 6603 Irongate Square North Chesterfield, VA 23234
Powhatan - 2164 Plainview Center Powhatan, VA 23139
Midlothian - 831 Grove Road, Suite C Midlothian, VA 23114
Do you have a preference on a male or female therapist?
How did you hear about us?
Other Online Source
Primary Care Physician
Tucker Psychiatric Clinic
Poplar Springs Hospital
Reason for counseling? (Brief summary)
Play Therapy - Children
Therapist Name (if you were directly referred to one)
EAP Management Company
If you are unsure of this number, please see the description at the top of the form.
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