USGB Acentra Referral Request Form

The Acentra Health EAP Referral Form powered by Life Expert, LLC, can be used to contact your Employee Assistance Program for work-life services and counseling support. Please complete the form to totality including a detailed overview of your needs.

Any request received during normal business hours, Monday-Friday, 8:30 am – 5:00 pm, will receive follow-up before close of business up to 24 hours. Requests received over the weekend or holidays will receive follow-up the next business day.

For all urgent requests, please call and speak with one of our EAP counselors immediately at 844-243-4440. Depending on the nature of your concerns, you may want to all 911 or the Suicide and Crisis Lifeline at 988.

What Company / Organization do you work for?:

Other Language:

Name:

First NameLast Name

Date of Birth:

Date

PhoneEmail

Phone Number:*

Please enter a valid phone number.Format: (000) 000-0000.

YesNo

Email:*

example@example.com

YesNo

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

YesNo

If this is an emergency, please call and speak with one of our EAP counselors immediately at 844-243-4440. Depending on the nature of your concerns, you may want to all 911 or the Suicide and Crisis Lifeline at 988.

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

Additional comments:

Employee Information:

Case Details: