* Company Name:
Your Counselor's Name:
How did you hear about the EAP?	EAP Brochure EAP Orientation  Human Resources Supervisor Co-Worker Union Family Member COPE WebSite Other:

1. My call was answered promptly when I initially contacted the EAP:

1	2	3	4	5	6	7
Strongly Disagree						Strongly Agree

2. The individual who answered my initial call was courteous & helpful:

1	2	3	4	5	6	7
Strongly Disagree						Strongly Agree

3. The EAP Counselor with whom I met understood my problems:

1	2	3	4	5	6	7
Strongly Disagree						Strongly Agree

4. My EAP Counselor helped me develop an action plan for resolving my problems:

1	2	3	4	5	6	7
Strongly Disagree						Strongly Agree

If you were referred to a counseling or community resource after meeting with the EAP, please answer the following questions; if not, please go to question 8:

Name of referral:

5.The referral resource was affordable:

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Strongly Disagree						Strongly Agree

6.The referral resource really helped me resolve my problems:

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Strongly Disagree						Strongly Agree

7. If I had a similar problem in the future, I would use this resource again:

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Strongly Disagree						Strongly Agree

8.Do you believe that the problem you sought help for from the EAP was affecting your work performance/attendance?

Yes No

If Yes, please answer the following questions; if No, go to question 11.

9. Do you believe your work performance/attendance has improved since seeking help from the EAP?

Yes No

If Yes, please answer the following question; if No, go to question 11.

10. How much has your work performance improved since recieving EAP assistance?

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Not Much At All						A Whole Lot

11. Overall, my satisfaction with my EAP experience is

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Very Low						Very High

12. If I had a similar problem in the future, I would seek help from the EAP again:

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Definitely No						Definitely Yes