Request Counselling

Who are you? *

Are you covered by an Employee Assistance Program? *

Yes

No

Are you covered by a Student Assistance Program? *

Yes

No

If yes, are you currently enrolled at the institution? *

Yes

No

What can we do for you? *

Date of Request Submission

Please tell us a little more about yourself:

Company/Institution name *

First name *

Last name *

Gender *

Email *

Phone *

Extension

Address *

City *

Postal Code *

Province *

Date of Birth *

We may contact you by phone?

Is there a best time to contact you?

Marital Status *

Do you have a preference on the gender of counsellor you would like to work with?

If not employed by the company, what relation are you to employee? (e.g. spouse, child)

Please provide a brief description of the issue(s) for which you are seeking support: *

Have you ever received any support or treatment in the past? If so, briefly explain: *

Are you currently experiencing any thoughts of hurting yourself or anyone else, or are you experiencing any violence or abuse? If so, please explain: *

Do you have any concerns related to alcohol or drugs? If yes, please explain: *

In the past two weeks have you been feeling down or depressed? *

Yes

No

In the past two weeks have you been feeling anxious? *

Yes

No

May we contact you via your listed email address or phone number and leave a message? *

Yes

No

Please compose your first message. Describe your current situation including any important background information. Focus on your main concern and how it is impacting you in terms of your thoughts, feelings, and behaviours. Identify your goals for seeking counselling at this time and what you want to achieve. Please be as descriptive as you wish. *

Consent *

Yes

I understand by clicking on this box, I am providing my expressed consent to receive electronic communications including emails about new services and promotions from HumanaCare. I understand I may withdraw my consent at any time by emailing HumanaCare.

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Request Counselling

Request Counselling

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