Client Needs Analysis Form Please enable JavaScript in your browser to complete this form.Client Company Name *Date of referral *Client Contact Person Name *Designation *Contact Information Tel (W) *Cell Number *Email Address *Address Physical *Postal *Website *Market sector and nature of businessIndustryFinancialFinancialRetailServicesITInsuranceHealthcareMiningManufactureUnion (if applicable)Work SitesNo. of work sitesWork Site 1Cityi.e. JohannesburgEmployees per sitei.e. 10Work Site 2Cityi.e. JohannesburgEmployees per sitei.e. 10Work Site 3Cityi.e. JohannesburgEmployees per sitei.e. 10Work Site 4City i.e. JohannesburgEmployees per sitei.e. 10Work Site 5City i.e. JohannesburgEmployees per sitei.e. 10Work Site 6City i.e. JohannesburgEmployees per sitei.e. 10Work Site 7Cityi.e. JohannesburgEmployees per sitei.e. 10Work Site 8Cityi.e. JohannesburgEmployees per sitei.e. 10Work Site 9Cityi.e. JohannesburgEmployees per sitei.e. 10Work Site 10Cityi.e. JohannesburgEmployees per sitei.e. 10If Work sites > 10, please submit a detailed work site list below Click or drag a file to this area to upload. Employee ProfileNumber of Employees *Average number of dependents per employee *Demography (Estimate %) *Employees *Management *Healthcare InsurerCompany AppointedIndividual SelectionRetirement Fund AdministratorCompany AppointedIndividual SelectionDisability InsurerCurrent Employee Wellness Service ProviderOrganisation NameCurrent engagement utilization rateCurrent number of critical incidents per yearCurrent contract termNotice period (Months)DigitCan you provide a copy of the latest annual EAP report?YesNoCurrent Employee Wellness Service ProviderPlease specify the services that you feel would contribute to achieving your vision/outcomesSelect the relevant services mentioned below. If you have requirements that are not listed below please indicate this to the lifeassist representative who will contact you Contract types & specialized complimentary services *Employee Assistance ProgrammeEmployee Assistance ProgrammeWorkplace absenteeism managementOnsite testingHIV post exposure-prophylaxis (PEP)Critical Incident/Trauma responseHealth Risk ScreeningRestructuring supportExecutive wellnessChronic disease managementCompany wellbeing profilingPolicy development and reviewEnergy managementFitness programmeErgonomicsDieticianCSI IntegrationWorkplace Support GroupsEAP ModelClinically Appropriate Model *Employee Assistance ProgrammeEmployee Assistance ProgrammeWorkplace absenteeism managementOnsite testingHIV post exposure-prophylaxis (PEP)Critical Incident/Trauma responseHealth Risk ScreeningRestructuring supportExecutive wellnessChronic disease managementCompany wellbeing profilingPolicy development and reviewEnergy managementFitness programmeErgonomicsDieticianCSI IntegrationWorkplace Support GroupsSession Limited Model *Employee Assistance ProgrammeEmployee Assistance ProgrammeWorkplace absenteeism managementOnsite testingHIV post exposure-prophylaxis (PEP)Critical Incident/Trauma responseHealth Risk ScreeningRestructuring supportExecutive wellnessChronic disease managementCompany wellbeing profilingPolicy development and reviewEnergy managementFitness programmeErgonomicsDieticianCSI IntegrationWorkplace Support GroupsNumber of sessions per case *EligibilityEmployee (Includes: Permanent staff, contractors, temporary workers and other) *Employee Assistance ProgrammeEmployee Assistance ProgrammeWorkplace absenteeism managementOnsite testingHIV post exposure-prophylaxis (PEP)Critical Incident/Trauma responseHealth Risk ScreeningRestructuring supportExecutive wellnessChronic disease managementCompany wellbeing profilingPolicy development and reviewEnergy managementFitness programmeErgonomicsDieticianCSI IntegrationWorkplace Support GroupsSpouse / Partner *Employee Assistance ProgrammeEmployee Assistance ProgrammeWorkplace absenteeism managementOnsite testingHIV post exposure-prophylaxis (PEP)Critical Incident/Trauma responseHealth Risk ScreeningRestructuring supportExecutive wellnessChronic disease managementCompany wellbeing profilingPolicy development and reviewEnergy managementFitness programmeErgonomicsDieticianCSI IntegrationWorkplace Support GroupsFinancial Dependent Children *Employee Assistance ProgrammeEmployee Assistance ProgrammeWorkplace absenteeism managementOnsite testingHIV post exposure-prophylaxis (PEP)Critical Incident/Trauma responseHealth Risk ScreeningRestructuring supportExecutive wellnessChronic disease managementCompany wellbeing profilingPolicy development and reviewEnergy managementFitness programmeErgonomicsDieticianCSI IntegrationWorkplace Support GroupsFinancial Dependent Household *Employee Assistance ProgrammeEmployee Assistance ProgrammeWorkplace absenteeism managementOnsite testingHIV post exposure-prophylaxis (PEP)Critical Incident/Trauma responseHealth Risk ScreeningRestructuring supportExecutive wellnessChronic disease managementCompany wellbeing profilingPolicy development and reviewEnergy managementFitness programmeErgonomicsDieticianCSI IntegrationWorkplace Support GroupsDomestics *Employee Assistance ProgrammeEmployee Assistance ProgrammeWorkplace absenteeism managementOnsite testingHIV post exposure-prophylaxis (PEP)Critical Incident/Trauma responseHealth Risk ScreeningRestructuring supportExecutive wellnessChronic disease managementCompany wellbeing profilingPolicy development and reviewEnergy managementFitness programmeErgonomicsDieticianCSI IntegrationWorkplace Support GroupsCounselling TypeFace to FaceEmployee Assistance ProgrammeEmployee Assistance ProgrammeWorkplace absenteeism managementOnsite testingHIV post exposure-prophylaxis (PEP)Critical Incident/Trauma responseHealth Risk ScreeningRestructuring supportExecutive wellnessChronic disease managementCompany wellbeing profilingPolicy development and reviewEnergy managementFitness programmeErgonomicsDieticianCSI IntegrationWorkplace Support GroupsOnlineEmployee Assistance ProgrammeEmployee Assistance ProgrammeWorkplace absenteeism managementOnsite testingHIV post exposure-prophylaxis (PEP)Critical Incident/Trauma responseHealth Risk ScreeningRestructuring supportExecutive wellnessChronic disease managementCompany wellbeing profilingPolicy development and reviewEnergy managementFitness programmeErgonomicsDieticianCSI IntegrationWorkplace Support GroupsTeleEmployee Assistance ProgrammeEmployee Assistance ProgrammeWorkplace absenteeism managementOnsite testingHIV post exposure-prophylaxis (PEP)Critical Incident/Trauma responseHealth Risk ScreeningRestructuring supportExecutive wellnessChronic disease managementCompany wellbeing profilingPolicy development and reviewEnergy managementFitness programmeErgonomicsDieticianCSI IntegrationWorkplace Support GroupsE-mailEmployee Assistance ProgrammeEmployee Assistance ProgrammeWorkplace absenteeism managementOnsite testingHIV post exposure-prophylaxis (PEP)Critical Incident/Trauma responseHealth Risk ScreeningRestructuring supportExecutive wellnessChronic disease managementCompany wellbeing profilingPolicy development and reviewEnergy managementFitness programmeErgonomicsDieticianCSI IntegrationWorkplace Support GroupsWhatsappEmployee Assistance ProgrammeEmployee Assistance ProgrammeWorkplace absenteeism managementOnsite testingHIV post exposure-prophylaxis (PEP)Critical Incident/Trauma responseHealth Risk ScreeningRestructuring supportExecutive wellnessChronic disease managementCompany wellbeing profilingPolicy development and reviewEnergy managementFitness programmeErgonomicsDieticianCSI IntegrationWorkplace Support GroupsOnsite ClinicsIndicate number of sites onsite clinics are required atNumber of days per weekNumber of hours onsite per monthAccessibility Via TeleClient specific numberSelect the appropriate option/sEmployee Assistance ProgrammeEmployee Assistance ProgrammeWorkplace absenteeism managementOnsite testingHIV post exposure-prophylaxis (PEP)Critical Incident/Trauma responseHealth Risk ScreeningRestructuring supportExecutive wellnessChronic disease managementCompany wellbeing profilingPolicy development and reviewEnergy managementFitness programmeErgonomicsDieticianCSI IntegrationWorkplace Support GroupsGeneric numberSelect the appropriate option/sEmployee Assistance ProgrammeEmployee Assistance ProgrammeWorkplace absenteeism managementOnsite testingHIV post exposure-prophylaxis (PEP)Critical Incident/Trauma responseHealth Risk ScreeningRestructuring supportExecutive wellnessChronic disease managementCompany wellbeing profilingPolicy development and reviewEnergy managementFitness programmeErgonomicsDieticianCSI IntegrationWorkplace Support GroupsToll Free numberSelect the appropriate option/sEmployee Assistance ProgrammeEmployee Assistance ProgrammeWorkplace absenteeism managementOnsite testingHIV post exposure-prophylaxis (PEP)Critical Incident/Trauma responseHealth Risk ScreeningRestructuring supportExecutive wellnessChronic disease managementCompany wellbeing profilingPolicy development and reviewEnergy managementFitness programmeErgonomicsDieticianCSI IntegrationWorkplace Support GroupsShare Call numberSelect the appropriate option/sEmployee Assistance ProgrammeEmployee Assistance ProgrammeWorkplace absenteeism managementOnsite testingHIV post exposure-prophylaxis (PEP)Critical Incident/Trauma responseHealth Risk ScreeningRestructuring supportExecutive wellnessChronic disease managementCompany wellbeing profilingPolicy development and reviewEnergy managementFitness programmeErgonomicsDieticianCSI IntegrationWorkplace Support GroupsEmailSelect the appropriate option/sEmployee Assistance ProgrammeEmployee Assistance ProgrammeWorkplace absenteeism managementOnsite testingHIV post exposure-prophylaxis (PEP)Critical Incident/Trauma responseHealth Risk ScreeningRestructuring supportExecutive wellnessChronic disease managementCompany wellbeing profilingPolicy development and reviewEnergy managementFitness programmeErgonomicsDieticianCSI IntegrationWorkplace Support GroupsSMS (Shortcode)Select the appropriate option/sEmployee Assistance ProgrammeEmployee Assistance ProgrammeWorkplace absenteeism managementOnsite testingHIV post exposure-prophylaxis (PEP)Critical Incident/Trauma responseHealth Risk ScreeningRestructuring supportExecutive wellnessChronic disease managementCompany wellbeing profilingPolicy development and reviewEnergy managementFitness programmeErgonomicsDieticianCSI IntegrationWorkplace Support GroupsWhatsAppSelect the appropriate option/s Employee Assistance ProgrammeEmployee Assistance ProgrammeWorkplace absenteeism managementOnsite testingHIV post exposure-prophylaxis (PEP)Critical Incident/Trauma responseHealth Risk ScreeningRestructuring supportExecutive wellnessChronic disease managementCompany wellbeing profilingPolicy development and reviewEnergy managementFitness programmeErgonomicsDieticianCSI IntegrationWorkplace Support GroupsUSSDSelect the appropriate option/sEmployee Assistance ProgrammeEmployee Assistance ProgrammeWorkplace absenteeism managementOnsite testingHIV post exposure-prophylaxis (PEP)Critical Incident/Trauma responseHealth Risk ScreeningRestructuring supportExecutive wellnessChronic disease managementCompany wellbeing profilingPolicy development and reviewEnergy managementFitness programmeErgonomicsDieticianCSI IntegrationWorkplace Support GroupsWebsiteSelect the appropriate option/sEmployee Assistance ProgrammeEmployee Assistance ProgrammeWorkplace absenteeism managementOnsite testingHIV post exposure-prophylaxis (PEP)Critical Incident/Trauma responseHealth Risk ScreeningRestructuring supportExecutive wellnessChronic disease managementCompany wellbeing profilingPolicy development and reviewEnergy managementFitness programmeErgonomicsDieticianCSI IntegrationWorkplace Support GroupsLifetrack AppSelect the appropriate option/sEmployee Assistance ProgrammeEmployee Assistance ProgrammeWorkplace absenteeism managementOnsite testingHIV post exposure-prophylaxis (PEP)Critical Incident/Trauma responseHealth Risk ScreeningRestructuring supportExecutive wellnessChronic disease managementCompany wellbeing profilingPolicy development and reviewEnergy managementFitness programmeErgonomicsDieticianCSI IntegrationWorkplace Support GroupsReportingFrequencyMonthlyMonthlyQuarterlyAnnualOtherSelect the appropriate option/s Employee Assistance ProgrammeEmployee Assistance ProgrammeWorkplace absenteeism managementOnsite testingHIV post exposure-prophylaxis (PEP)Critical Incident/Trauma responseHealth Risk ScreeningRestructuring supportExecutive wellnessChronic disease managementCompany wellbeing profilingPolicy development and reviewEnergy managementFitness programmeErgonomicsDieticianCSI IntegrationWorkplace Support GroupsOther descriptionPro-Active EngagementHealth Promotion MaterialsWallet cardsWallet cardsHandbooksPostersHandoutsDesk-dropsBannersOnsite ActivityFrequency: AnnualFrequency: OtherOther descriptionSelect the appropriate option/sEmployee Assistance ProgrammeEmployee Assistance ProgrammeWorkplace absenteeism managementOnsite testingHIV post exposure-prophylaxis (PEP)Critical Incident/Trauma responseHealth Risk ScreeningRestructuring supportExecutive wellnessChronic disease managementCompany wellbeing profilingPolicy development and reviewEnergy managementFitness programmeErgonomicsDieticianCSI IntegrationWorkplace Support GroupsCommunicationSMS'sSMS'sMonthly Health NewslettersMonthly emailsOutgoing callsSelect the appropriate option/sEmployee Assistance ProgrammeEmployee Assistance ProgrammeWorkplace absenteeism managementOnsite testingHIV post exposure-prophylaxis (PEP)Critical Incident/Trauma responseHealth Risk ScreeningRestructuring supportExecutive wellnessChronic disease managementCompany wellbeing profilingPolicy development and reviewEnergy managementFitness programmeErgonomicsDieticianCSI IntegrationWorkplace Support GroupsOnline WellnessWebsiteWebsiteMobileSelect the appropriate option/sEmployee Assistance ProgrammeEmployee Assistance ProgrammeWorkplace absenteeism managementOnsite testingHIV post exposure-prophylaxis (PEP)Critical Incident/Trauma responseHealth Risk ScreeningRestructuring supportExecutive wellnessChronic disease managementCompany wellbeing profilingPolicy development and reviewEnergy managementFitness programmeErgonomicsDieticianCSI IntegrationWorkplace Support GroupsTrainingStaff induction (# of 1-hour training sessions)Select the appropriate option/sEmployee Assistance ProgrammeEmployee Assistance ProgrammeWorkplace absenteeism managementOnsite testingHIV post exposure-prophylaxis (PEP)Critical Incident/Trauma responseHealth Risk ScreeningRestructuring supportExecutive wellnessChronic disease managementCompany wellbeing profilingPolicy development and reviewEnergy managementFitness programmeErgonomicsDieticianCSI IntegrationWorkplace Support GroupsManager induction (# of 2-hour training sessions)Select the appropriate option/sEmployee Assistance ProgrammeEmployee Assistance ProgrammeWorkplace absenteeism managementOnsite testingHIV post exposure-prophylaxis (PEP)Critical Incident/Trauma responseHealth Risk ScreeningRestructuring supportExecutive wellnessChronic disease managementCompany wellbeing profilingPolicy development and reviewEnergy managementFitness programmeErgonomicsDieticianCSI IntegrationWorkplace Support GroupsPower Hours (# of Power hours to be allocted)Select the appropriate option/sEmployee Assistance ProgrammeEmployee Assistance ProgrammeWorkplace absenteeism managementOnsite testingHIV post exposure-prophylaxis (PEP)Critical Incident/Trauma responseHealth Risk ScreeningRestructuring supportExecutive wellnessChronic disease managementCompany wellbeing profilingPolicy development and reviewEnergy managementFitness programmeErgonomicsDieticianCSI IntegrationWorkplace Support GroupsPower Hours (R value per Power Hour)Select the appropriate option/s Employee Assistance ProgrammeEmployee Assistance ProgrammeWorkplace absenteeism managementOnsite testingHIV post exposure-prophylaxis (PEP)Critical Incident/Trauma responseHealth Risk ScreeningRestructuring supportExecutive wellnessChronic disease managementCompany wellbeing profilingPolicy development and reviewEnergy managementFitness programmeErgonomicsDieticianCSI IntegrationWorkplace Support GroupsSpecialised TrainingSpecify topicSelect the appropriate option/sEmployee Assistance ProgrammeEmployee Assistance ProgrammeWorkplace absenteeism managementOnsite testingHIV post exposure-prophylaxis (PEP)Critical Incident/Trauma responseHealth Risk ScreeningRestructuring supportExecutive wellnessChronic disease managementCompany wellbeing profilingPolicy development and reviewEnergy managementFitness programmeErgonomicsDieticianCSI IntegrationWorkplace Support Groups# of hours per sessionSelect the appropriate option/sEmployee Assistance ProgrammeEmployee Assistance ProgrammeWorkplace absenteeism managementOnsite testingHIV post exposure-prophylaxis (PEP)Critical Incident/Trauma responseHealth Risk ScreeningRestructuring supportExecutive wellnessChronic disease managementCompany wellbeing profilingPolicy development and reviewEnergy managementFitness programmeErgonomicsDieticianCSI IntegrationWorkplace Support Groups# of sessionsSelect the appropriate option/s Employee Assistance ProgrammeEmployee Assistance ProgrammeWorkplace absenteeism managementOnsite testingHIV post exposure-prophylaxis (PEP)Critical Incident/Trauma responseHealth Risk ScreeningRestructuring supportExecutive wellnessChronic disease managementCompany wellbeing profilingPolicy development and reviewEnergy managementFitness programmeErgonomicsDieticianCSI IntegrationWorkplace Support GroupsWellness DaysFrequencySelect the appropriate option/sEmployee Assistance ProgrammeEmployee Assistance ProgrammeWorkplace absenteeism managementOnsite testingHIV post exposure-prophylaxis (PEP)Critical Incident/Trauma responseHealth Risk ScreeningRestructuring supportExecutive wellnessChronic disease managementCompany wellbeing profilingPolicy development and reviewEnergy managementFitness programmeErgonomicsDieticianCSI IntegrationWorkplace Support GroupsLifeAssist full event managementYesYesNoSelect the appropriate option/s Employee Assistance ProgrammeEmployee Assistance ProgrammeWorkplace absenteeism managementOnsite testingHIV post exposure-prophylaxis (PEP)Critical Incident/Trauma responseHealth Risk ScreeningRestructuring supportExecutive wellnessChronic disease managementCompany wellbeing profilingPolicy development and reviewEnergy managementFitness programmeErgonomicsDieticianCSI IntegrationWorkplace Support GroupsLifeAssist participationYesYesNoSelect the appropriate option/s Employee Assistance ProgrammeEmployee Assistance ProgrammeWorkplace absenteeism managementOnsite testingHIV post exposure-prophylaxis (PEP)Critical Incident/Trauma responseHealth Risk ScreeningRestructuring supportExecutive wellnessChronic disease managementCompany wellbeing profilingPolicy development and reviewEnergy managementFitness programmeErgonomicsDieticianCSI IntegrationWorkplace Support GroupsSpecificy stakeholders to be includedSubmit