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Confidential Online Request Form for Daily Living Issues


Use this form to request referrals for legal matters, ID theft or its prevention, mindfulness coaching, elder/adult care, nutrition coaching, tobacco cessation, and financial counseling. Please note that IMPACT is not able to provide referrals for employment law. IMPACT does not provide investment advice or financial assistance. Additional resources are also available on your IMPACT Website.


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 this form. Please call our 24/7 toll-free number at 800-678-6265.


We request the following information as a quick and convenient way to refer you to an appropriate professional. Our questions screen for your health and safety, which is our primary concern. Please do not complete a request for another adult (18 years or older), they MUST complete the request themselves. If you are requesting services for a minor child, please include your name, date of birth, relationship to the employee, and contact information in the Additional Comments Section.

An IMPACT Triage Counselor will reach out to you within one business day with regard to your on-line request.


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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)
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If you have requested follow up by email (particularly GMAIL users), please be sure to check your spam/junk folders as messages can be commonly filtered.
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Work Impact
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