Sand Creek

Intake Form to Access Services

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If you are in crisis or have an urgent need, please call Sand Creek directly at 888.243.5744 to speak with a Sand Creek Clinician.


If you would like to access EAP services, please fill out the intake form and click on "Submit Form" after the Special Instructions question. An EAP Intake Consultant will respond to your request by calling you at your desired contact number within 1 business day. Staff office hours are Monday-Thursday 7:30 am to 5:00 pm, Friday 7:30 am to 3:00 pm CT.


If you do not hear from a Sand Creek Intake Consultant within 1 business day, we did not receive your on-line submission form. Please give us a call to speak directly with us.


All information is kept confidential from your employer, unless you give explicit, written consent to share your information.


* Indicates Required Fields

Employee/Member's Information
Employer/Membership
Employee/Member's First Name
Employee/Member's Last Name
Requester's Information
First NameIf you are not the employee
Last NameIf you are not the employee
Date of Birth
AddressAddress 1
Address 2
City
Zip Code
Contact Phone Number
Extension
Special Instructions
0 /
I agree that I am submitting this form for myself or a minor for whom I am legal guardian.
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