Online requests will receive a response within two business days. This service request feature should not be used for urgent or emergency situations. If you need immediate assistance call the following toll-free number: 866-719-5788,+442089875966, 911, or go to your nearest hospital emergency room.

What is the name of the company through which you have EAP services?*

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Your first name:*

Your last name:*

Your address:*

Street

City

State --- Select --- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip

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Your phone number:*

Your e-mail address:*

Verify your e-mail address:*

How may we contact you?(check all that apply)*

Phone

E-mail

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Is this your first time using the EAP?*

Yes

No

Gender:*

Male

Female

Date of Birth:*

(mm/dd/yyyy)

Participation status:* --- Select --- Employee Spouse Dependent Household Member

Please tell us about the issue you are seeking assistance for?*

Maximum characters:1000

If you are seeking counseling, would you like us to contact you to set up a time for telephone counseling or video counseling?*

Yes

No

If you have a preference for seeing someone in person, have you selected a provider from the ReferralConnect network list ?

Yes

No

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What is the name and the address of the provider you have selected from the network list?

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Provider first name:

Provider last name:

Provider Address:

Street

City

State --- Select --- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip

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Your request will be kept confidential and you will receive a response within two business days. If you need immediate assistance, please call us 24/7 on the following toll-free number: 866-719-5788,+442089875966. Please do not schedule an appointment with the provider you have selected prior to receiving confirmation of your authorization for services. This request feature should not be used in an urgent or emergency situation. If you believe that you have an emergency medical or behavioral condition, get care immediately by going to the nearest hospital emergency room or by calling 911.