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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

How can we help you?

Please tell us a little more about yourself

First Name

Last Name

Date of Birth

Phone Type

Phone

Extension

OK to leave message?

OK to email?

Address

City/Town

State/Province

ZIP/Postal Code

Relationship Status

Preferred method of communication

How did you learn about the Assistance Program?

Who referred you to the Assistance Program?

Please rate the impact of your issue on work/school

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

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.