BridgeWorks Sign Up

This form is intended for BridgeWorks sign up with Canopy EAP. If you found this form by mistake or need assistance with signing up a new group please email info@canopywell.com or call 800-433-2320.

BridgeWorks Sign Up

Your Email Address

General Information

First Name

M.I.

Last Name

Phone

DBA Company Name

Legal Company Name (If different from above)

Address (Please be sure to include Street, City, State, and Zip)

Company and Benefits

Industry Type

Number of eligible employees

Eligibility Criteria

All Employees Benefit Eligible Employees Only Other

Eligibility Criteria: If you answered "other" please provide additional information

Eligibility Criteria: Other

Multiple Locations

Yes, we have multiple locations No, we only have one location

If you answered "yes" please provide the city and state of each location in the "locations" section below. Or you may email your account manager your list.

Health Insurance

EAP Services

Contact your Customer Success Manager for pricing questions.

Additional EAP Services

3 Sessions ($3.10) 6 Sessions ($3.60)

Additional Information

Please share any additional information

Preferred Start Date