EAP Referral Form

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

Referral Details

• Referral Date
  Date the referral is being made.
• Referral Source
  Who initiated the referral.
• If other, describe referral source
  Provide a brief description if the referral source is not listed.
• Your relationship to the employee
  Select the role of the person completing the form.
• If other, describe your relationship
• I understand this referral will be handled confidentially and shared only with authorized personnel as needed for support and follow-up.
  Required acknowledgment before submitting a confidential referral.

Employee Information

• Employee Name
  Enter the employee’s name only if needed for follow-up and routing.
• Employee ID
  Optional internal identifier if your organization uses one.
• Department
  Department or team, if relevant to the referral.
• Work Location
  Optional location or site information.
• Preferred Contact Method
  How the employee prefers to be contacted, if applicable.

Concern and Referral Reason

• Primary Concern
  Select the main reason for the referral.
• If other, describe the concern
• Brief Summary of Concern
  Provide a concise, factual summary. Avoid unnecessary personal details.
• Observed Impact on Work
  Select any observed work-related impacts.
• Urgency Level
  Choose the level of urgency based on current circumstances.

Risk, Consent, and Accommodation

• Is there an immediate safety risk requiring urgent intervention?
  If yes, follow your emergency response process immediately.
• Brief Risk Details
  Provide only the minimum necessary details for response and escalation.
• Employee consented to this referral
  Indicate whether the employee agreed to the referral or whether this is a manager/HR initiated referral.
• Consent / Disclosure Notes
  Document any disclosure or consent language used, if applicable.
• Is a reasonable accommodation discussion needed?
  Use this to route ADA-related follow-up when appropriate.
• Accommodation Notes
  Describe the request at a high level without collecting unnecessary medical details.

Available Resources and Follow-Up

• Resources Shared
  Select all resources that were provided or discussed.
• Follow-Up Owner
  Who is responsible for the next step.
• If other, describe follow-up owner
• Follow-Up Date
  Date for the next check-in or review.
• Follow-Up Action Plan
  Document the agreed next steps, including any outreach, check-in, or referral actions.
• Submitter Signature
  Optional signature for internal audit trail or acknowledgment.