Contact Us - Helpdesk

Issue: *

Link to report if available

Member Last Name *

Member First Name *

Personal Email Address *

Legal First Name *

Legal Last Name *

If you have more than one last name, please provide the last name you prefer to use for your email.

Gender *

Date Of Birth *

Street *

City *

State *

Zip Code *

Phone Number *

Phone Type *

Allow SMS? (Mobile Phone Required) *

Spanish Speaking? *

Degree (ex. Master of Social Work)

First Year of Related Work Experience (ex. 1999) *

NPI Number *

If you are a Behavioral Coach, please use 0000000000 NOTE: if you are a Therapist and do not have an NPI Please go to https://nppes.cms.hhs.gov/ and follow the instructions on the left to apply.

Pick Temporary Password *

Must be 10 Characters Minimum Must have at least 1 Symbol Must have at least 1 Uppercase Must have at least 1 Lowercase Must have at least 1 Number Cannot Contain your username This will only be used to initially log in and set your permanent password.

Role *

Choose Supervisor: *

Laptop Type

Laptop ready by?

Remote Employee?

Participant First Name *

Participant Last Name *

Best time to contact Participant

Type of Referral *

If substance use is present, is the participant open to sharing those details with the health plan?

Why does the participant need this referral? (This will be sent to the health plan verbatim) What action does the health plan need to take with this member? (e.g. support the member to link to appropriate resources, provide behavioral health CM oversight) *

Please list comorbid medical and behavioral health conditions *

Does the Participant Agree to the Requested Referral? *

Have you made any referrals for this participant (Only for Aetna BH referrals)? *

If you have made any referrals for this Participant, please list provider names and contact information; otherwise type N/A *

Please list Participant's Psychiatric Diagnoses (Only for Aetna BH and MAP referrals; otherwise, type N/A): *

Looker Report URL:

Health plan ID/EnAbleTo ID *

Joyable Product

Program

Partner Name

Company Name *

User First Name *

User Last Name *

User Email Address *

User Mobile Number

What date do you need these created by? (Note: Please provide minimum of 1 business day of notice) *

Standard trial accounts are one week long. Is this case an exception?

Participant Health Plan *

Age Range

Location

City, State, Zip

Transportation Access

Phone Access

Yes or No

Internet/Computer Access

Yes or No

Preferred Language

Gender ID

Pronouns

Open to Religious Affiliated Organization

Yes or No

Request type *

Please select one.

Should you be the assigned Therapist for treatment?

Product *

Behavior Coach

If the product is Therapy +, please mirror the Therapist date/time above.

:

Programs *

What kind of device are you using?

What do you see under "Can't access company resources?"

Urgency Level *

Participant ID (numbers only)

Does this need to be addressed within the next 24 hours? *

Best time to contact

:

Employee Type

Requested Leave Start Date

Estimated Return Date

The Reason for this Leave Request

The reason for this leave request is (select the most appropriate box):

Birth of a son or daughter and to care for the newborn child. Placement with the employee of a son or daughter for adoption or foster care. To care for the employee's spouse, son, daughter or parent with a serious health condition. A serious health condition that makes the employee unable to perform the functions of the employee's job. COVID related illness or caregiving responsibilities A qualifying exigency arising out of the fact that the employee's spouse, son, daughter or parent is a military member on covered active duty (or has been notified of an impending call or order to covered active duty status). To care for a covered servicemember with a serious injury or illness if the employee is the spouse, son, daughter, parent or next of kin of the covered service member. To care for the employee’s child when the employee is unable to work (or telework) due to the closing of the child’s school, place of care, or unavailability of the regular childcare provider due to a public health emergency with respect to COVID-19. Other: Type In Message Box Below

Time Off Work Expected To Be

Additional information about employee leave of absence rights (including FMLA) and responsibilities will be provided to you in writing within five business days after receipt of this notice (unless already provided). Determination of eligibility for leave under FMLA and other leave of absence laws and/or additional documentation or clarification of documentation, may be required prior to making a final determination to approve any leave request. Please contact People Operations with any questions. Please return this form with documentation supporting your request for a leave of absence. (physician’s statement, military orders, or additional information)

Employee Signature *

Type in your name. This represents your signature.

Your Phone Number

City/State *

Supervisor Name

Description of Disability *

Describe the nature, extent and duration of your disability.

Describe Accommodations *

Describe the accommodations you believe are needed to enable you to perform the essential functions of this job.

Attach any supporting documentation below that may be helpful in evaluating this request for accommodation.

By Clicking 'Submit' I authorize the release of information regarding my disability to AbleTo management as deemed necessary by human resources to facilitate this request for accommodation. Depending on the accommodation, we may request health care provider information in regards to your impairment/disability and recommendations for accommodations. Attach any supporting documentation below that may be helpful in evaluating this request for accommodation.

Session to be rescheduled? *

For example ( IC, 1A, 1B) **If there are multiple reschedules for the same Participant, please add details in the "Message" box below.

Reassignment Role *

Upcoming Session *

For example (IC, 1A, 1B)

Do session(s) also need to be rescheduled? *

If yes, please include rescheduling information in the message box below.

Reassignment Reason *

Other Schedule request needed *

Date/Time *

:

Time Zone *

Type of Change? *

Change requested? *

Type of request *

Type of treatment change

Participant ID (Mandatory) *

You can't submit without there being a value in this field. (Limit one Participant ID per ticket)

Mail Request *

Which System? *

What occurred? *

Please explain in detail what you are facing.

What did you expect to occur? *

Department *

Subject *

Message *

Name *

Email *

Category *