Online Request Form for Mass General Brigham Assistance Program Services for Employees
This form is for setting up non-urgent appointments only.
If you are experiencing a life-threatening situation, or if you are experiencing suicidal thoughts, homicidal thoughts or domestic violence, DO NOT complete this form. Please call 911 or go to the nearest emergency room.
We request the following information as a quick and easy way to schedule an appointment with one of our counselors.
* denotes required field
We will contact you by email within 1 business day to schedule an appointment. Please note the appointment confirmation email is sent from email@example.com. Typically, we schedule appointments within 3-5 business days from date of contact. If your matter is urgent, please call 866-724-4327. Please check all options that apply.
Mass General Brigham Assistance Program Consent to Email
If you prefer not to authorize the use of email, we will continue to use U.S. Mail, fax or the telephone to communicate with you.
By indicating “yes” on this form, I authorize the Mass General Brigham Assistance Program to communicate with me via email. The most secure ways for us to communicate with you via email are to stay within the Mass General Brigham firewall using your Mass General Brigham/Partners email or send you an email on your personal account that is encrypted by “send secure”.
By signing the bottom of this form, I understand the use of unsecure/unencrypted email has some risk of interception (being read by others) and I understand these risks.