Signature is required

Service Requester (Please remember that all of your information is confidential unless you request that we release information or in the event that you are a threat to yourself or someone else)

Organization/Institution providing Student Assistance benefit

Relationship to Organization/Institution

How can we help you?

ElderCare / Adult Care

Who is the individual(s) requiring the service?

How old is the individual(s)?

Is this a long-distance caregiving situation?

When (days and hours) is care needed?

When are you looking for care to begin?

What physical or cognitive impairment(s) does the individual have?

What type of care does the individual require?

What type of elder care resource are you looking for?

Adult Day Care

Geriatric Care Manager

Doctors

Medical Supplies/Equipment

Financial Assistance

Home Care

Hospice

Support Groups

Transportation

Housing

Other

What type of elder care resource are you looking for? (Other)

Does the caregiver need to provide transportation?

How will you or the individual be paying?

What is the individual’s monthly income?

Does the individual have advance directives or will?

What primary search area? (city, state, postal code)

What secondary search area? (city, state, postal code)

Please include any additional information.

Child Care

Your child's date of birth (Day/Month/Year):

Your Second child's date of birth (Day/Month/Year):

Your third child's date of birth (Day/Month/Year):

Your Fourth child's date of birth (Day/Month/Year):

On which day(s) is care needed?

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Hours/Time of care?

When do you need services to start?

Will the Schedule rotate or vary

Will the Schedule rotate or vary:*

Yes

Will the Schedule rotate or vary (Other)

What is the primary search area? Near Home, Work, Other? Please provide zip codes or cities?

If before or after-school care is needed, what school does your child(ren) attend?

Does the child have any special needs or allergies the child care provider would need to accommodate?

Do you have any preference regarding pets?

Is your child potty trained?

Do you have a budget?

Is there a provider(s) you would not like us to contact?

HOUSING

Is this an emergency housing request?

Is this an emergency housing request?:*

Yes

Rental property search locations?

What type of rental are you looking for? (Ex: Apartments, House/Town home, Shared/Roommate)

How much can you afford a month for rent?

Do you need utilities included in this monthly price?

How many bedrooms do you need?

Do you have any pets? What size?

Tentative move-in date?

Are there any other specifics you would like included in the search? (Ex: Garage, W/D Hook Up, Yard)

Are you looking for low income housing information?

Are you looking for low income housing information?:*

Yes

Legal

Please note: The legal benefit does not cover: Labor or Employment Law, FMLA or Social Security Disability claims.

Do we have permission to leave a voicemail in the event we need to contact you by phone?

Do we have permission to leave a voicemail in the event we need to contact you by phone?:*

Yes

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

In what county and state is the attorney needed for the legal issue?

Please select the reason for seeking an attorney:

Bankruptcy

Child Custody

Civil Litigation

Criminal Law

Divorce

Elder Law

Estate Planning

Family Law

Homeowners Association Law

Landlord and Tenant Law

Medical Malpractice

Personal Injury

Power of Attorney

Real Estate

Traffic Violations

Trusts and Estates

Wills and Probate

Other

Medical Advocacy

Issue of concern or health related question to be addressed by the medical advocate or medical professional:

Obtaining a diagnosis

Finding a provider

Getting a second opinion

Claim related question

Other

Issue of concern or health related question to be addressed by the medical advocate or medical professional: (Other)

Name of medical insurance:

Insurance Member ID #:

Insurance phone #:

Please include any other additional information to consider:

Financial

Please note: While your organization may offer specific programming that offers financial funding, AllOne Health Student Assistance Programs do not provide money for financial hardships or help with household expenses. However, our financial counselors are happy to help you by providing resources within your community that may be able to assist you with any financial hardship need.
Please allow 2 to 3 business days for resource support.

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

Additional comments (financial):

Life Coaching

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

Additional comments (coaching):

Availability

Personal Assistance

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

Additional comments (personal assistance):

Other Work Life Request

Please provide a brief description of the issue(s) for which you are seeking support (other work life request)

Additional comments (other work life request):

Please tell us a little more about yourself

First Name

Last Name

Date of Birth

Phone Type

Phone

Extension

OK to leave message?

OK to email?

Address

City/Town

State/Province

ZIP/Postal Code

Relationship Status

Preferred method of communication

How did you learn about the Assistance Program?

Who referred you to the Assistance Program?

Please rate the impact of your issue on work/school

How many days of work/school have you missed due to this issue

ASSISTANCE PROGRAM STATEMENT OF UNDERSTANDING AND AGREEMENT ON CONFIDENTIALITY:

Confidentiality Information you provide to your Assistance Program is confidential and will not be disclosed without your written consent except as set forth below:
1. Abuse or neglect of a child, dependent adult, or person with a disability,
2. Threat of bodily harm to yourself or someone else,
3. As mandated by a court order or law, or
4. With your signed consent.
Fees
1. Please consult with your insurance or benefits representative before you access services outside of the Assistance Program provider network.
2. There may be costs associated with the referrals provided that are not covered by the Assistance Program.
Complaints of Harassment and/or Discrimination Discussion of concerns about potential workplace/school harassment, violations of organizational policy and/or discrimination with your counselor are not considered official notification to your employer/school. To do so you will need to follow your organization’s policy.

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*

Sign Here Using Mouse or Finger/Stylus Use Keyboard

We may match you with a third-party provider. We are not responsible for the data use practices of third-party providers. By pressing the “Submit” button, you consent to us sharing your personal information with a third-party provider.

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Student Assistance Work Life Form

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