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.