Corporate Wellness Program Interest Form
The purpose of this form is to identify employers, who you as their employee(s) are interested in improving their physical, mental, and emotional health to gauge their interest in offering resources, support and guidance provided by Her-bal to help you as their employee(s) achieve your overall wellness goals.

Your Name*
Your Employer*
The Human Resources (Email)*
The Human Resources (Phone Number)
Are there any resources and/or support that you feel would be beneficial in helping to improve your mental and/or physical health at work?
Does your employer have an Employee Assistance Program and/or Wellness Program?*
Yes
No
I'm not sure
What would you like to see your Employer offer within an Employee Assistance Program and/or Wellness Program?*