Counseling Interest Form

Please correct the errors described below.
Please type full name, as noted on Social Security Card
*Needed to Verify Insurance and Coverage
*Information is needed to qualify for "Financial Hardship Assistance"

If you do not have NC Driver's License and/or Insurance Card, write "N/A" on paper and upload picture as an alternative.

    Please upload a file
      Please upload a file
        Please upload a file
        **Request from EAP or HR
        *Cell Phone Service / Needed to troubleshoot connection w/ virtual sessions

        Your information will be encrypted.

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