EAP Client Contact and Disposition Report

Please complete this report when you have seen a CMGA client for EAP evaluation.  A report should be sent following each client contact. You may complete this form online and press “Send” at the bottom of the page to e-mail it to us (keep a copy for your own records). Click here for an Adobe version of the form to print and fax it to us at 617-969-7646.

Client name:      

Client telephone: 

Client Company: 

Presenting problem: 

Date of contact:  

Please state briefly your findings and disposition:

Did you refer the client for further treatment?    Yes No

If yes, name, address, and telephone of referral person/agency:

Your name, address (include name of agency), and telephone:

Thank you very much for seeing this client.