EAP Referral Form

A confidential form for documenting employee concerns, referral reasons, available resources, and follow-up actions for Employee Assistance Program support.

Referral Details

• Referral Date
  Date the referral is being submitted.
• Referral Source
  Who is making the referral?
• If other, specify referral source
• Employee Department
  Department helps route the referral without collecting unnecessary PII.
• Work Location
  Optional. Include only if location is needed for local support coordination.
• Confidentiality acknowledgment
  I understand this form may contain sensitive PII and will be handled confidentially by authorized personnel only.

Concern and Referral Reason

• Primary concern
  Select the main reason for referral.
• If other, describe the concern category
• Brief summary of concern
  Provide a concise summary of the issue and its impact. Avoid unnecessary personal details.
• How long has this concern been present?
• Observed work impact
  Select all that apply.
• If other, describe observed work impact

Risk, Accommodation, and Immediate Support

• Is there an immediate safety risk?
  Choose Yes if there is a risk of harm to self or others, or another urgent safety concern.
• If yes or unsure, describe the immediate risk
• Is a workplace accommodation being requested?
  Use this to identify whether ADA reasonable-accommodation follow-up may be needed.
• Accommodation details
• Urgent support requested
  Check if the employee needs same-day contact or expedited follow-up.

Consent and Disclosure

• Employee consent to refer to EAP
  The employee consents to this referral and understands that information will be shared only with authorized support personnel as needed.
• Information sharing acknowledgment
  I understand that only the minimum necessary information will be shared to coordinate support.
• Preferred contact method
• Contact preferences or restrictions
  Include preferred times, accessibility needs, or contact restrictions.

Resources and Follow-Up

• Resources offered
  Select all resources that were offered or discussed.
• If other, specify resource offered
• Follow-up owner
• Follow-up date
  Date for the next check-in or review.
• Follow-up actions
  Document the next steps, including any referrals made and any action items.