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Run: 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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Referral Details

Referral Date (required)

Referral Source (required)

Primary Reason for Referral (required)

Brief Summary of Concern (required)

Provide a concise, factual summary of the concern without unnecessary personal details.

Employee Information

Employee Name (required)

Employee ID

Department

Work Location

Preferred Contact Method

Confidentiality and Consent

Confidentiality Acknowledged (required)

Yes No N/A

Consent to Share Information with EAP Provider (required)

Information Sharing Notes

Note any limitations on information sharing or special confidentiality considerations.

Support Resources

Resources Provided (required)

Immediate Support Needed (required)

Support Details

Describe any immediate actions, accommodations, or support steps already taken.

Risk and Urgency

Urgency Level (required)

Safety Concern Present

Yes No N/A

Risk Notes

Include only factual observations relevant to urgency or safety.

Follow-Up Plan

Follow-Up Owner (required)

Follow-Up Date

Follow-Up Method

Follow-Up Notes

Document agreed actions, check-in timing, and any additional notes.

Get your results

Enter your email — we'll send you a PDF of your filled-out template. We won't sign you up to anything; you can opt in to the trial from the email if you want.

Email (required)

Your name (optional)

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