Request a Counseling Appointment

We’re glad you’re here. The agencies contracted with us provide short-term counseling services at no cost to employees and eligible family members.

Please complete the form below with as much information as possible so we can confirm eligibility and connect you with care. After you submit your request, here’s what you can expect:
  1. Our team will verify that your employer has an active contract with us.
  2. We will create a secure account for you and send an email invitation to complete intake paperwork to help speed up the process.
  3. A member of our staff will reach out to discuss scheduling options based on the information you provided.
We will respond within one business day of your submission.

If you are experiencing an urgent concern or are in crisis, please call 1-800-222-9691 option 1 for immediate assistance.
Requestor Details
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Client Details
Format: MM/DD/YYYY
Full legal name of the agency or department (no acronyms please)
Please select the option that best applies.
For covered party
Contact Information for scheduling / follow up
Start typing in address, then select to auto-fill fields
Indicate scheduling preferences below: