Confidential Online Request Forms

Need Assistance? Select The Form Below That Best Fits Your Needs.

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 these forms, call 911.

Request Form for Counseling

If you want to schedule an appointment with a counselor to address personal, work or life stressors, please complete this form.

Request Form for Daily Living Issues

Use this form to request work/life resources and referrals that are designed to assist you. These items can include but are not limited to legal/financial, child care, pet care, housing services, education, elder and adult care and more.

AllOne Health Family of Assistance Programs

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