BECOME A CLIENT We look forward to discussing your needs. Please fill out this online form, or download the pdf to assist us to understand your needs. Client Your Name Designation Email Address Organisation Website: Contact Number Alternate Contact Number Physical Address City: Province: Market Sector: Number of Worksites: Locations of Worksites: About your staff Please complete as much information as you have available about your staff No. of Staff Demographic % Est. Management Average no. of Dependents Demographic % Est. Employees Demographic % Est. Employees Heathcare Insurer: Company appointed Yes Individual selection Yes If company selected, please provide supplier: Retirement Fund: Company appointed Yes Individual selection Yes If company selected, please provide supplier: Disability Insurer: Existing or Previous Services Organisation: Engagement Utilisation Rate: Contract Term/Notice period: Scope and Objectives: of your Employee Wellbeing Programme Employee Wellness Programme (EWP): Generic LifeAssist Yes Client co-brand Yes 24/7 Access Toll free Yes Share Call Yes SMS Yes Email Yes Counselling and Advice: ONSITE: Allowed at workplace, ad hoc Yes ONSITE: Clinic Yes OFFSITE Yes Induction Training: Management Yes Staff Yes Reporting: Utilisation Frequency Yes Satisfaction Survey Yes Specialised Complimentary Services Absenteeism Management Yes HIV Post Exposure Prophylaxis (PEP) Yes Critical Incident/Trauma response Yes Restructuring support Yes Company profiling: Engagement Surveys Yes Stress Assessments Yes Health Risk Screening: Cholesterol, BP etc. Yes HCT (HIV) Yes Executive Health Medical Assessments Yes Energy Management: Fitness programme: ONSITE GYM Yes Fitness programme: Other: workplace driven Yes Ergonomics Dietician: Review canteen menu Yes Ergonomics Dietician: Group sessions Yes Ergonomics Dietician: Individual sessions Yes Policies: Life-threatening diseases (incl. HIV and TB) Yes Substance Abuse Yes EWP Yes Proactive Engagement: Wellness Days: LifeAssist presence only Yes Wellness Days: LifeAssist full event management Yes Frequency Financial Wellness Frequency: Specialised Training: Life Skills Yes Policy implementation Yes Peer Educators Yes Peer Educators Workplace Support Groups Online Wellness: Website Yes Mobile Yes Thank you: Thank you for taking the time to complete this form. We will be able to get back to you with a more accurate proposal. Please feel free to call us to discuss your needs! Any additional information: Proposed Presentation Date: SUBMIT FORM