Confidential Online Request Form for Daily Living Issues
If you are experiencing a life-threatening situation, please call 911 or immediately go to an emergency room.
If you are experiencing suicidal thoughts, homicidal thoughts, or domestic violence, DO NOT complete this form. Please contact your Assistance Program.
Use this form to request work/life resources and referrals that are uniquely designed to assist you. These items may include, but are not limited to, legal/financial, elder and child care, housing information, medical advocacy, coaching, personal assist services and more.
* denotes required field
Signature is required
Service Requester (Please remember that all of your information is confidential unless you request that we release information
or
in the event that you are a threat to yourself or someone else)
Employer/Organization/Institution providing EAP benefit
*
Relationship to Employer/Organization/Institution
*
Loading…
How can we help you?
*
Loading…
Please tell us a little more about yourself
First Name
*
Last Name
*
Date of Birth
*
Loading…
May 2023
Sun
Mon
Tue
Wed
Thu
Fri
Sat
18
30
1
2
3
4
5
6
19
7
8
9
10
11
12
13
20
14
15
16
17
18
19
20
21
21
22
23
24
25
26
27
22
28
29
30
31
1
2
3
23
4
5
6
7
8
9
10
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Today
Clear
Phone Type
*
Loading…
Phone
*
Extension
OK to leave message?
*
Loading…
Email
OK to email?
Loading…
Address where you’re
CURRENTLY
living
*
City/Town
*
State/Province
*
Loading…
ZIP/Postal Code
*
Relationship Status
*
Loading…
Preferred method of communication
*
Loading…
How did you learn about the Assistance Program?
*
Loading…
Who referred you to the Assistance Program?
*
Loading…
Please rate the impact of your issue on work/school
*
Loading…
How many days of work/school have you missed due to this issue
*
Details
Please provide a brief description of the issue(s) for which you are seeking support
Additional comments
We may match you with a third-party provider. We are not responsible for the data use practices of third-party providers. By pressing the “Submit” button, you consent to us sharing your personal information with a third-party provider.
Submit
ASSISTANCE PROGRAM STATEMENT OF UNDERSTANDING AND AGREEMENT ON CONFIDENTIALITY:
Confidentiality
Information you provide to your Assistance Program is confidential and will not be disclosed without your written consent except as set forth below:
abuse or neglect of a child, dependent adult, or person with a disability,
threat of bodily harm to yourself or someone else,
as mandated by a court order or law, or
with your signed consent.
Fees
Please consult with your insurance or benefits representative before you access services outside of the Assistance Program provider network.
There may be costs associated with the referrals provided that are not covered by the Assistance Program.
Complaints of Harassment and/or Discrimination
Discussion of concerns about potential workplace/school harassment, violations of organizational/school policy and/or discrimination with your counselor are not considered official notification to your employer/school. To do so you will need to follow your organization’s/school’s policy.
By accepting below I acknowledge that I have read and understand the above statement and that I agree to proceed pursuant to the terms set forth above.
Consent Full Name
*
Sign Here Using Mouse or Finger/Stylus
Use Keyboard
Clear