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Career Counseling Appointment Request
*Required
Employee ID Number *
Your Employer ID does not contain any letters, numbers only. (For KP employees, this is NOT your NUID).
Your answer
Last Name *
Your answer
First Name *
Your answer
Middle Name
Your answer
Home Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Cell Phone Number *
(or Best number to reach you)
Your answer
Birthdate *
MM
/
DD
/
YYYY
Sex
Racial/Ethnic Background *
Required
Email Address *
Please give us an email address you check often so that we can send you resources as well as speak to you
Your answer
Employer *
Facility *
If you are at a KP Medical Office choose the medical center or hospital closest to you. If you are at a Dignity Health Medical office choose Mercy Medical Group.
Date of Hire *
MM
/
DD
/
YYYY
Department *
Your answer
Job Title *
Your answer
Wage *
Your answer
Benefitted Eligible *
Required
Schedule *
Required
Union Representation *
Required
What Education Fund programs/services would you like more information about? *
Would you like to meet with a Career Counselor?
Please briefly explain the assistance that you are requesting
Your answer
What is your career goal? *
If you do not know what your career goal is, write "undecided"
Your answer
Career Counseling Release *
I understand that Education Fund career counselors adhere closely to the ethical standards established by the American Counseling Association (www.counseling.org). I understand that in keeping with these standards, my right to confidentiality will be honored, and my records, including the results of any career assessments, will be kept confidential. I understand that the law requires career counselors to breach confidentiality when there is reason to believe that there is immediate danger of harm to myself or others, including the possibility of child or elder abuse. I am aware that Education Fund career counselors are solely responsible for providing me with career and academic counseling, and are not permitted to act as licensed clinical social workers, psychiatrists, psychologists, substance abuse counselors, or marriage and family therapists. I understand that if questions or issues that are beyond the scope of practice of my career counselor arise during the career counseling process, I will be referred to an appropriate professional. (Enter your name in box below confirming that you understand and agree to this release)
Your answer
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