Acentra Health Training Request Form

All Acentra Health EAP training requests require four weeks’ notice for planning and coordination. Five business days’ notice is required when cancelling a training session.


All requests that require an approval from your EAP Coordinator, must be approved before submitting the request. If an approval is not needed, please proceed with submission.


Please contact your Account Manager, Kelly Rissky at Kelly.rissky@acentra.com with any questions about scheduling trainings.


*REQUIRED FIELDS*

 

Please provide the State Agency or University you work for:

 

Point of Contact

 

Please enter the point of contact's first and last name.

 

Please enter the point of contact's phone number.

 

Please enter the point of contact's email address.

 

Alternate Point of Contact

 

Please enter the alternate point of contact's first and last name.

 

Training Details

 

Please enter the title of the training request.

 

Please enter the date of the training request.

 
mm/dd/yyyy
 

Please enter the time of the training request.


*Please note that each training is typically one hour*.

 

Please select the time zone of the training request.

 

Please enter the number of expected participants for the training request.

 

Please add any applicable notes.

 
 

Please select the composition of the attendees of the training request.

 

Please select the training venue location.