EAP Referral Form
Document EAP referrals consistently, protect confidentiality, and track follow-up so employees get the right support without losing the thread.
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Overview
The EAP Referral Form is a confidential workplace record for documenting why an employee was referred to an Employee Assistance Program, what support was offered, and who owns the follow-up. It brings together referral details, employee information, consent, resource notes, urgency, and a clear action plan so the conversation does not disappear into scattered emails or informal manager notes.
Use this template when a manager, HR partner, or employee relations lead needs to record a support referral in a consistent way. It is especially useful when the situation involves stress, attendance concerns, performance changes, interpersonal conflict, or a possible safety issue that needs careful handling. The form helps teams stay organized while limiting the amount of sensitive information stored in one place.
Do not use this form as a general performance review, disciplinary memo, or medical record. It is also not the right tool for broad incident reporting when the issue is unrelated to employee support. If the concern requires immediate emergency response, legal escalation, or a separate workplace investigation, this form should be used only as the referral and follow-up record, not as the sole source of truth.
Standards & compliance context
- Keep the form confidential and limit access to staff who need the information to provide support or manage risk.
- Avoid unnecessary medical or personal detail so the record stays focused on workplace support and not private health documentation.
- Document consent and information-sharing limits clearly when the employee agrees to share only specific details.
- If a safety concern is identified, follow your organization's escalation procedures and any applicable workplace safety or duty-of-care requirements.
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 captures why the referral happened and creates the factual starting point for the record.
- Referral Date
- Referral Source
- Primary Reason for Referral
-
Brief Summary of Concern
Provide a concise, factual summary of the concern without unnecessary personal details.
Employee Information
This section identifies the employee and the right contact details so follow-up reaches the correct person.
- Employee Name
- Employee ID
- Department
- Work Location
- Preferred Contact Method
Confidentiality and Consent
This section documents privacy expectations and what information can be shared, which is critical for trust and compliance.
- Confidentiality Acknowledged
- Consent to Share Information with EAP Provider
-
Information Sharing Notes
Note any limitations on information sharing or special confidentiality considerations.
Support Resources
This section shows what help was offered so the referral is tied to real support actions, not just a note.
- Resources Provided
- Immediate Support Needed
-
Support Details
Describe any immediate actions, accommodations, or support steps already taken.
Risk and Urgency
This section helps the team separate routine referrals from situations that need immediate attention or escalation.
- Urgency Level
- Safety Concern Present
-
Risk Notes
Include only factual observations relevant to urgency or safety.
Follow-Up Plan
This section assigns ownership and timing so the referral moves from intake to action and review.
- Follow-Up Owner
- Follow-Up Date
- Follow-Up Method
-
Follow-Up Notes
Document agreed actions, check-in timing, and any additional notes.
How to use this template
- 1. Set up the form with only the fields your HR or employee relations process needs, and restrict access to people who handle confidential employee support.
- 2. Enter the referral details first, including the date, source, reason, and a brief summary that stays factual and avoids unnecessary personal detail.
- 3. Record the employee information and note how the employee prefers to be contacted so follow-up happens through the least disruptive channel.
- 4. Capture confidentiality acknowledgment, consent to share, and any limits on information sharing before documenting resources or next steps.
- 5. Assign the follow-up owner, date, and method, then review the form after the first contact to update actions, risks, and unresolved items.
Best practices
- Keep the referral summary factual and short, and describe observable workplace concerns rather than speculation.
- Document the employee's preferred contact method before scheduling follow-up so outreach respects privacy and availability.
- Record exactly which resources were provided, such as the EAP contact path, crisis line, leave options, or internal support contacts.
- Use the urgency and safety fields to separate routine support referrals from situations that need immediate escalation.
- Assign one clear follow-up owner so the referral does not depend on shared assumptions or informal handoffs.
- Limit information sharing notes to what the employee agreed to disclose and who is authorized to receive it.
- Review the form after each follow-up touchpoint so the record reflects current status, not just the original referral.
What this template typically catches
Issues teams running this template most often surface in practice:
Common use cases
Frequently asked questions
What is an EAP Referral Form used for?
It is used to document when an employee is referred to an Employee Assistance Program and to capture the reason for referral, resources offered, and next steps. The form helps HR, managers, and support staff keep a clear record without relying on informal notes or memory. It also supports consistent follow-up while keeping sensitive information limited to what is necessary.
How often should this form be completed?
Complete it each time an EAP referral is made, whether the referral comes from a manager, HR, a supervisor, or the employee themselves. If the situation changes materially, update the form rather than creating disconnected notes elsewhere. A single referral can also be revisited during follow-up if the support plan changes.
Who should fill out and manage the form?
Usually the person making the referral or coordinating the response fills it out, such as HR, a manager, or an employee relations specialist. Access should be limited to people who need the information to support the employee and manage risk appropriately. The follow-up owner should be clearly assigned so the referral does not stall after the initial conversation.
Does this form have a compliance or privacy angle?
Yes. EAP referrals often involve sensitive employee information, so the form should reinforce confidentiality, consent, and limited information sharing. It should avoid unnecessary medical detail and keep notes focused on support actions and workplace impact. Local privacy, employment, and recordkeeping rules may also affect how the form is stored and who can view it.
What are the most common mistakes when using an EAP referral form?
Common mistakes include writing overly detailed personal notes, skipping consent fields, and failing to assign a follow-up owner. Another issue is using vague urgency labels without documenting the actual concern or immediate support needed. Teams also sometimes forget to record what resources were offered, which makes later follow-up inconsistent.
Can this template be customized for different workplaces?
Yes. You can add fields for union status, shift schedule, manager name, case reference number, or internal escalation paths if your process requires them. You can also simplify the form for smaller teams or expand it for organizations with formal employee relations workflows. The key is to preserve the confidentiality, consent, and follow-up sections.
What tools does this form integrate with?
It can work alongside HRIS platforms, case management systems, secure document storage, and task trackers. Many teams also connect it to calendar tools for follow-up dates and internal notification workflows for assigned owners. If you use a ticketing or case system, the form can serve as the intake record that feeds the case.
How should we roll this out to managers and HR staff?
Start by defining who can initiate a referral, who can view the form, and how follow-up is assigned. Then train managers on what to document, what not to document, and when to escalate urgent safety concerns. A short rollout guide with examples usually helps teams use the form consistently from day one.
How is this better than ad-hoc notes or email threads?
Ad-hoc notes make it harder to track consent, resources, urgency, and follow-up in one place. Email threads can also expose sensitive information to the wrong people and create version confusion. A structured form gives you a cleaner record, clearer ownership, and a more controlled way to handle confidential employee support.
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