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Need Assistance?

Please submit the following information in order for us to assist you. All information is confidential and will be reviewed to determine assistance eligibility.
Name
Home Address
Phone
Email
Gender
Date of Birth
Date of Traumatic Event
Have you sought out psychological or medical treatment for symptoms associated with this Traumatic Event?
Are you currently on or seeking Disability determination?
Are you currently or have been involved or in the process of litigation regarding this Traumatic Event?
Do you currently have Medical Insurance?
If you have Medical Insurance, which Insurance Plan do you currently have?
Aetna
Blue Cross/Blue Shield
Highmark Blue Cross/Blue Shield
Independence Blue Cross/Blue Shield
ValueOptions
United Health
Kaiser
Cigna
Amerihealth
MHNet
Tricare
Sierra Military
Total Care Network
Devon
Medicare
Humana
Medicaid
Magellan
PCHS
Beechstreet
Health Administrators
Employee Assistance Program (EAP)
Other
Have you ever been diagnosed by a physician, psychiatrist, psychologist, social worker, or any other health care professional with a mental health or substance abuse disorder?
In the space provided, please describe the nature of the Traumatic Event:
After reviewing your answers, a member of our staff will contact you.