Life Balance Services

Online Request for Life Balance Services

Life Balance Services include Adult Care, Financial Services, Legal Referrals, Emergency Housing Services, and Parenting and Child Care Resources.

For immediate support, please call Concern's 24/7 toll-free number at 800.344.4222.

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

* denotes required field

Caller Information

Company Name*:

Your Company Division / Location (if applicable):

First Name*:

Last Name*:

Please tell us a little about yourself

Street Address*:

Apt/Suite Number:

City*:

State*:

Postal Code*:

Phone Type*:

Phone number to contact you*:

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Does Concern have your permission email and/or text you?*:

E-mail Address*:

Does Concern have your permission to email you?*:

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.

Preferred method of communication*:

Employee Date of Birth*:

Your Gender:

Additional Information

Client Status*:

Years of Service to Employer*:

Source of Referral*:

Type of Service Requested*:

Please provide a brief description of your situation*:

Submit

EAP STATEMENT OF UNDERSTANDING AND AGREEMENT ON CONFIDENTIALITY:
Information you provide to an Employee Assistance Program(EAP) Coordinator during a counseling session is confidential. EAP will not disclose the information without your written consent except as set forth below:

EAP may disclose confidential information if it concerns abuse or neglect of a child, dependent adult, or disabled person.
EAP may disclose confidential information if it concerns the infliction of bodily harm or the intent to inflict bodily harm on a person.
EAP may disclose confidential information if King County is served with a subpoena compelling disclosure.
EAP may disclose confidential information if disclosure is reasonably necessary for YOUR Employer, its departments, divisions, agencies, and employees to defend against any charges or claims by the employee, related to the employee’s EAP counseling session(s).
EAP may disclose confidential information if EAP determines that disclosure is reasonably necessary to prevent a direct threat to the health or safety of yourself or others during the performance of your job.
If your department has directed you to meet with an EAP Coordinator for any reason, including the department’s concern about your use of alcohol and drugs, EAP may disclose:

whether you have kept mandatory appointments;
whether you are compliant with EAP recommendations and other treatment recommendations;
whether EAP recommends your return to duty; and
whether there are any known restrictions in the performance of your job.

EAP will not disclose other confidential information unless it falls within exceptions 1 - 6 above or you give your written permission to EAP to disclose it. If you believe that you have a medical condition that requires a reasonable accommodation, or if you wish to report discrimination or retaliation in the workplace, EAP will not disclose these facts unless you give EAP written permission to do so.

By accepting below I acknowledge that I have read and understand the above statement and that I agree to proceed pursuant to the terms set forth above.

Consent Full Name*

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A Concern representative will be contacting you within one business day in order to complete your request.

For assistance with this request in a language other than English, please call 800-344-4222 for language assistance.