EAP Referral Form
An EAP Referral Form for documenting the concern, referral reason, consent, and follow-up actions in one confidential record. Use it to route employees to support while keeping PII limited and the next steps clear.
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Overview
The EAP Referral Form template captures the minimum information needed to document a support referral, explain why the referral was made, record consent and disclosure acknowledgments, and assign follow-up. It is designed for confidential HR workflows where an employee may need access to counseling, coaching, crisis support, or other assistance through an Employee Assistance Program.
Use this template when a manager, HR partner, or employee relations lead needs a consistent way to record a concern without turning the form into a disciplinary file. The structure works well for stress, attendance changes, interpersonal conflict, performance concerns linked to personal circumstances, or an urgent support request. Conditional logic keeps the form short by showing risk, accommodation, or urgent support fields only when they apply.
Do not use this template as a general incident report, a medical intake form, or a broad investigation questionnaire. It should not collect unnecessary PII, diagnosis details, or unrelated personal history. If your process allows anonymous submission, keep that option separate and clearly explain what information can still be shared. The best version of this form leaves the reader knowing exactly what was documented, what resources were offered, who owns the next step, and when follow-up will happen.
Standards & compliance context
- Limit collection to the minimum necessary information and avoid unnecessary PII to align with GDPR data minimization and internal privacy controls.
- If the form is used for health-related support, keep it focused on referral logistics and minimum-necessary details rather than medical intake content.
- For HR intake use cases, include an accommodation prompt only when relevant so the form can support ADA reasonable-accommodation routing without overcollecting.
- Provide a clear consent and disclosure acknowledgment before sharing information beyond the referral workflow, and retain an audit trail for follow-up actions.
General regulatory context for orientation only — verify current requirements with counsel or the relevant agency before relying on this template for compliance.
What's inside this template
Referral Details
This section identifies who is making the referral, when it happened, and where the case belongs so the record can be routed correctly.
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Referral Date
Date the referral is being submitted.
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Referral Source
Who is making the referral?
- If other, specify referral source
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Employee Department
Department helps route the referral without collecting unnecessary PII.
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Work Location
Optional. Include only if location is needed for local support coordination.
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Confidentiality acknowledgment
I understand this form may contain sensitive PII and will be handled confidentially by authorized personnel only.
Concern and Referral Reason
This section explains why the referral is being made and what work impact has been observed, which keeps the record focused on the support need.
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Primary concern
Select the main reason for referral.
- If other, describe the concern category
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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?
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Observed work impact
Select all that apply.
- If other, describe observed work impact
Risk, Accommodation, and Immediate Support
This section captures only the higher-sensitivity details that matter when there may be immediate risk or a need for workplace support.
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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
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Is a workplace accommodation being requested?
Use this to identify whether ADA reasonable-accommodation follow-up may be needed.
- Accommodation details
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Urgent support requested
Check if the employee needs same-day contact or expedited follow-up.
Consent and Disclosure
This section documents permission and communication preferences so the employee understands how information will be shared and how follow-up will happen.
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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.
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Information sharing acknowledgment
I understand that only the minimum necessary information will be shared to coordinate support.
- Preferred contact method
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Contact preferences or restrictions
Include preferred times, accessibility needs, or contact restrictions.
Resources and Follow-Up
This section records what support was offered, who owns the next step, and when the case should be checked again.
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Resources offered
Select all resources that were offered or discussed.
- If other, specify resource offered
- Follow-up owner
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Follow-up date
Date for the next check-in or review.
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Follow-up actions
Document the next steps, including any referrals made and any action items.
How to use this template
- 1. Set the referral date, department, location, and referral source fields so the record identifies where the concern came from and who initiated it.
- 2. Configure conditional logic for risk, accommodation, and urgent support fields so only the sections that apply appear to the person completing the form.
- 3. Assign the follow-up owner before rollout and define who receives the submission so the referral does not sit without action.
- 4. Complete the concern summary, work impact, consent, and resources offered fields using plain language and only the PII needed for support.
- 5. Review the follow-up date and actions after submission, then update the record with outcomes, routing changes, or additional support steps.
Best practices
- Mark required fields sparingly and keep optional fields clearly labeled so the form does not feel punitive or overbroad.
- Use a date picker for referral_date and follow_up_date, numeric input only where counts are needed, and multi-select for resources offered.
- Add a clear line that explains what happens after submission, including who can view the record and how follow-up will occur.
- Use progressive disclosure for risk and accommodation questions so sensitive details appear only when the initial answer indicates they are relevant.
- Collect only the PII needed to route support and avoid asking for diagnosis, family history, or other details that do not change the referral.
- Include a preferred contact method and notes field so follow-up respects privacy, shift schedules, and employee availability.
- Keep the confidentiality acknowledgment visible near the consent section so the employee understands the limits of sharing before submitting.
What this template typically catches
Issues teams running this template most often surface in practice:
Common use cases
Frequently asked questions
Who should use an EAP Referral Form?
HR, managers, supervisors, and designated employee relations staff typically use this form when an employee may benefit from EAP support. It is also useful for documenting a self-referral when your process allows it. The form should be completed by the person making the referral, with the employee’s consent captured when required. Keep the audience limited to people who need the record for support and follow-up.
What situations does this template cover?
This template fits concerns such as stress, attendance changes, conflict, performance issues tied to personal circumstances, or requests for support resources. It also works when a manager needs to document a referral after observing a work impact. It is not a disciplinary write-up and should not be used to collect unrelated personal details. Use conditional logic so only the fields that apply are shown.
How often is an EAP Referral Form used?
It is usually completed each time a referral is made or a new concern is escalated. If the situation changes, create a new entry or update the existing record according to your retention and audit trail rules. Do not reuse one form for multiple unrelated employees or incidents. A clear referral date and follow-up date help keep the record current.
What should be included in the form and what should be left out?
Include the referral source, concern summary, duration, work impact, immediate risk, consent, resources offered, and follow-up actions. Leave out unnecessary PII, medical details, and anything not needed to connect the employee to support. Use progressive disclosure so sensitive fields appear only when relevant. This supports GDPR data minimization and reduces overcollection.
How does this form handle confidentiality and consent?
The form should include a confidentiality acknowledgment and a clear consent or disclosure section before any information is shared beyond the referral process. If your workflow allows anonymous submission for a concern report, make that option explicit and explain its limits. State what happens after submission, who can see the record, and how the information will be used. That transparency helps employees understand the process before they submit.
What are the most common mistakes when using this template?
Common mistakes include making every field required, asking for too much personal detail, and using free-text fields where a date picker or multi-select would be better. Another issue is skipping the follow-up owner or follow-up date, which leaves the referral unresolved. Some teams also forget to document consent or preferred contact method. Those gaps make the record harder to act on and harder to defend as a controlled HR process.
Can this template be customized for different departments or locations?
Yes. You can tailor the referral source options, work impact choices, resources offered, and follow-up actions by department, site, or region. If you operate across multiple locations, add location-specific routing or conditional logic for local support contacts. Keep the core fields consistent so the record remains comparable across cases.
What integrations or workflow steps pair well with this form?
This form pairs well with case management, HRIS, ticketing, and secure document storage workflows. After submission, route the record to the assigned follow-up owner and create an audit trail for any status changes. If your process includes notifications, limit them to the minimum necessary details. Avoid sending sensitive content through unsecured channels.
How is this different from an informal manager note or email?
An informal note is easy to lose, inconsistent, and usually missing consent, follow-up ownership, or a standard set of fields. This template creates a repeatable record with validation, required-vs-optional clarity, and a defined path for action. That makes it easier to support the employee, maintain confidentiality, and review the case later if needed. It also reduces the chance that important follow-up steps are missed.
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