To schedule an appointment or request services, please complete the following form or call us at 1-800-344-1011.

1 Step 1

Request Services

Namefull name

Date of Birth

date_range

Companyof covered employee

Emaila valid email address

email

Phone(daytime)

call e0b0

Ok to leave message?

YesNo

Preferred Method of Communication

EmailPhone

Best time to call

MorningAfternoonNo Preference

How did you hear about the EAP?Select all that apply

Co-WorkerHuman ResourcesManagerCompany PortalBenefit FairFamily MemberEAP Training Session/Orientation1

Details of your request for services

Service Request

Please Select OneCounselingLegal ServicesFinancial ServicesEldercare ServicesChildcare ServicesWork Life ServicesWellness CoachingSleep CoachingNursing Mother Assist

Provider Preference

MaleFemaleReligion (Please Specify)No Preference

Religious Preference

Best times to meet with a counselorPlease select all that apply

MorningAfternoonEveningsWeekends

Health Insurance

Select An OptionCignaAetnaBlueCross/BlueShieldUnitedHealthCareTuftsMassHealthMVP HealthcareHarvard PilgrimNeighborhood Health PlanKaiser PermanenteOther (Specify Below)

Other Health InsuranceType name if not in list above

Reason for seeking counseling(please provide)

0 /

Work Life ServicesBriefly describe what you are looking for

0 /

Location of services requested

Additional Information(optional)

0 /

Submit

keyboard_arrow_leftPrevious

Nextkeyboard_arrow_right