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Counseling Services

Online Request Form for Counseling Services


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, domestic violence, or substance abuse is the primary concern of your request, DO NOT complete this form. Please call Concern's 24/7 toll-free number at (800)344-4222.


We request the following information as a quick and easy way to refer you to a professional. Our questions screen for your health and safety, which is our primary concern.
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Caller Information
Please tell us a little more about yourself
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By checking this box, I hereby provide permission for Concern to send electronic information to the email address indicated and affirm my understanding that sending information to an email address may not be secure.
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Work Impact
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Additional Information
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Submit
This secure, online form is HIPAA compliant and powered by Medforward.

Concern will respond to your request within one business day. For assistance with this request in a language other than English, please call 800-344-4222 or click here for language assistance.


If you are experiencing suicidal thoughts, homicidal thoughts, or domestic violence, please call Concern's 24/7 toll-free number at (800)344-4222.