Employee Support Services Request

Please complete as much information as possible so that we can verify your eligibility for services. We will get back to you within 1 business day of your submission.

For urgent requests or if in crisis, please contact us at 1-800-222-9691.

Requestor Details

First Name

Last Name

Mobile Phone

Format: ###-###-####

Email

Assistance Requested

Urgent

Requestor Relationship

Brief Description

Client Details

First Name

Last Name

Birthdate

Format: MM/DD/YYYY

Gender

Covered Party

Agency/Employer (for covered party)

Full legal name of the agency or department (no acronyms please)

Covered Party's Full Name

Employee or Dependent under this Program?

Please select the option that best applies.

Sworn / Non-Sworn

For covered party

Contact Information for scheduling / follow up

Primary Reason for Request

Home Address (street)

Start typing in address, then select to auto-fill fields

City

State

Zip Code

Indicate scheduling preferences below:

Preferred Treatment Method

In PersonTelehealthNo Preference

Preferred Days

MonTueWedThuFriSatSun

Preferred Hours

MorningAfternoonEvening

Preferred Therapist Gender

Preferred Counseling Language

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Contact Information