EAP Referral Form
This EAP Referral Form captures the reason for referral, any immediate risk, consent, and follow-up actions in one confidential workflow. Use it to document employee support needs while limiting PII and keeping the next step clear.
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Overview
This EAP Referral Form template is for documenting an employee support referral in a structured, confidential way. It captures who made the referral, the concern that triggered it, whether the employee consented, whether there is immediate risk, and what resources or follow-up actions were shared.
Use it when a manager, HR partner, or designated support contact needs a consistent record of an EAP referral and the next steps. The template is especially useful when the issue may affect attendance, performance, conduct, or safety, or when the employee is asking for help and you need to route them to the right resources. It also gives you a place to note reasonable accommodation needs without burying that information in a freeform comment.
Do not use this form as a general performance review, a medical intake, or a disciplinary record. If your situation does not involve a referral to support resources, or if you do not need to collect consent, risk, and follow-up details, a simpler HR note or incident form may be a better fit. Keep the form focused on the minimum necessary information, and use conditional logic so sensitive fields only appear when they apply.
Standards & compliance context
- Collect only the minimum necessary PII and referral details needed to support the EAP process, consistent with data minimization principles.
- If the form is public-facing or employee-accessible, keep labels, validation, and navigation accessible in line with WCAG 2.1 AA.
- When accommodation needs are captured, separate that information from the referral narrative so HR can route it appropriately and maintain confidentiality.
- If the referral includes health-related information, restrict access and sharing to the minimum necessary audience and keep an audit trail of review and follow-up.
- Include consent and confidentiality acknowledgment language wherever personal or sensitive information is entered so the employee understands how the information will be used.
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 establishes who initiated the referral, when it happened, and whether the submitter acknowledged confidentiality before sharing any sensitive information.
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Referral Date
Date the referral is being made.
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Referral Source
Who initiated the referral.
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If other, describe referral source
Provide a brief description if the referral source is not listed.
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Your relationship to the employee
Select the role of the person completing the form.
- If other, describe your relationship
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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
This section identifies the employee and the safest way to reach them without collecting more PII than the referral requires.
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Employee Name
Enter the employee’s name only if needed for follow-up and routing.
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Employee ID
Optional internal identifier if your organization uses one.
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Department
Department or team, if relevant to the referral.
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Work Location
Optional location or site information.
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Preferred Contact Method
How the employee prefers to be contacted, if applicable.
Concern and Referral Reason
This section explains why the referral is being made and how the issue is affecting work so the reviewer can triage it quickly.
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Primary Concern
Select the main reason for the referral.
- If other, describe the concern
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Brief Summary of Concern
Provide a concise, factual summary. Avoid unnecessary personal details.
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Observed Impact on Work
Select any observed work-related impacts.
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Urgency Level
Choose the level of urgency based on current circumstances.
Risk, Consent, and Accommodation
This section captures urgent safety concerns, consent to refer, and any accommodation signal that needs separate handling.
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Is there an immediate safety risk requiring urgent intervention?
If yes, follow your emergency response process immediately.
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Brief Risk Details
Provide only the minimum necessary details for response and escalation.
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Employee consented to this referral
Indicate whether the employee agreed to the referral or whether this is a manager/HR initiated referral.
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Consent / Disclosure Notes
Document any disclosure or consent language used, if applicable.
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Is a reasonable accommodation discussion needed?
Use this to route ADA-related follow-up when appropriate.
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Accommodation Notes
Describe the request at a high level without collecting unnecessary medical details.
Available Resources and Follow-Up
This section records what support was shared, who owns the next step, and when the case should be reviewed again.
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Resources Shared
Select all resources that were provided or discussed.
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Follow-Up Owner
Who is responsible for the next step.
- If other, describe follow-up owner
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Follow-Up Date
Date for the next check-in or review.
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Follow-Up Action Plan
Document the agreed next steps, including any outreach, check-in, or referral actions.
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Submitter Signature
Optional signature for internal audit trail or acknowledgment.
How to use this template
- 1. Set the referral date, referral source, and employee relationship fields so the record shows who initiated the referral and in what context.
- 2. Enter only the employee information needed to identify the case and route follow-up, using the preferred contact method instead of collecting extra PII.
- 3. Describe the primary concern, summarize the impact on work, and select an urgency level so the reviewer can triage the referral quickly.
- 4. Record whether there is immediate risk, add only the risk details needed for action, and document whether the employee consented to the referral.
- 5. Note any resources shared, assign a follow-up owner and date, and write a clear action plan that states what happens after submission.
- 6. Capture the submitter signature or equivalent acknowledgment so the referral has an audit trail and a clear handoff point.
Best practices
- Use conditional logic to show risk details only when immediate risk is marked present, and hide accommodation notes unless they are needed.
- Mark required versus optional fields clearly so users do not over-collect information or abandon the form when only a few fields are essential.
- Keep the concern summary factual and behavior-based, not diagnostic or speculative, so the record stays useful and defensible.
- Offer anonymous submission only if your process truly supports it, and make sure the follow-up owner understands how anonymous referrals are handled.
- Use structured fields for urgency, contact method, and referral source instead of free text so reporting and routing stay consistent.
- Limit employee information to the minimum necessary for the referral and avoid collecting unrelated health or family details.
- State what happens after submission in the follow-up section so the submitter knows who reviews the case and when action will occur.
What this template typically catches
Issues teams running this template most often surface in practice:
Common use cases
Frequently asked questions
What is this EAP Referral Form used for?
This form is used to document why an employee is being referred to an Employee Assistance Program, what concern was observed, and what follow-up is needed. It also records consent, confidentiality acknowledgment, and any immediate risk details so HR or the referring manager has a clear record. The template is designed to support a confidential, structured referral rather than an informal note.
Who should complete the form?
It is typically completed by HR, a manager, a supervisor, or another designated referral owner who is involved in the concern. The employee may also complete parts of it if your process allows self-referral or shared completion. The form should clearly identify the submitter and the follow-up owner so responsibility does not get lost.
When should an EAP referral be made?
Use it when an employee’s personal or work-related concern is affecting attendance, performance, behavior, or safety and a referral to support resources is appropriate. It is also useful when the employee requests help and you need a documented path to resources. If there is an immediate safety issue, the form should route that concern to urgent response steps first, not just routine follow-up.
Does this form collect sensitive personal information?
It can, so the template should be configured with data minimization in mind. Only collect the PII and health-related details needed to support the referral, and avoid unnecessary fields such as diagnosis, full medical history, or unrelated personal background. Include a clear confidentiality acknowledgment and consent language wherever personal details are entered.
How often should follow-up be scheduled?
Follow-up timing depends on the urgency level and the support plan, but the form should always capture a specific follow-up date or review window. For urgent concerns, the follow-up owner may need to act the same day or within a very short period. For lower-risk referrals, a standard check-in date is usually enough to confirm the employee connected with resources.
What are common mistakes when using this template?
Common mistakes include making every field required, writing vague concern summaries, and skipping the consent or confidentiality acknowledgment. Another issue is using free-text fields for data that should be structured, such as urgency level or preferred contact method. The form should also avoid collecting more detail than the referral process actually needs.
How does this template support reasonable accommodation requests?
The accommodation section gives the submitter a place to note whether a reasonable accommodation may be needed and what type of support is being considered. That helps route the case to the right HR process without mixing it into the referral narrative. Keep this section separate from the concern summary so accommodation handling stays focused and documented.
Can this form be customized for different departments or locations?
Yes. You can adjust the referral source options, department fields, work location labels, and resource lists to match your organization’s structure. If different sites use different follow-up owners or local support resources, conditional logic can show the right options without exposing unnecessary fields to every user.
How is this different from an informal email referral?
An email can be hard to track, inconsistent, and easy to miss during handoffs. This template standardizes the referral details, captures consent and risk information, and creates a clearer audit trail for follow-up. It also helps ensure the same core fields are collected every time, which improves consistency and reduces omissions.
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