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Confidential Online Request Form for Counseling


If you are experiencing a life-threatening situation, please call 911 or immediately go to an emergency room.

If you are experiencing suicidal thoughts, homicidal thoughts, or domestic violence, DO NOT complete this form. Please call our 24/7 toll-free number at 800-678-6265.


We request the following information as a quick and convenient way to refer you to an appropriate professional. Our questions screen for your health and safety, which is our primary concern. Please do not complete a request for another adult (18 years or older) for individual counseling, they MUST complete the request themselves. If you are requesting services for a minor child, please include your name, date of birth, relationship to the employee, and contact information in the Additional Comments Section.

An IMPACT Triage Counselor will reach out to you within one business day with regard to your on-line request.


* denotes required field
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)
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Please tell us a little more about yourself
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If you have requested follow up by email (particularly GMAIL users), please be sure to check your spam/junk folders as messages can be commonly filtered.
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We only ask about your insurance so that we can select a provider in that network in case you need to go beyond your complimentary visits.
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Work Impact
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Recent Experience
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Provider (Mental Health Professional) Preferences
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Who will be attending counseling in addition to you? Please note that you are not permitted to request individual counseling services for another adult. Individuals 18 and over MUST request their own services. Indivudals 18 and over can be included in couples or family requests.
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Details
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