21st Century EAP


Service Request Form

This form is for routine service requests only.

If this an urgent request, please contact the EAP at 1-800-825-5327, ext. 621.

The Following Information is OPTIONAL but completing them will help us assist you faster.
If you wish to skip these fields and submit only your contact information, then please click the submit button at the bottom of the form.

Have you used EAP services before? If so, please tell us the last date you utilized EAP services.

How did Learn about EAP services?

Present your reason/need for services: