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Run: 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 ...

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Referral Details

Referral Date (required)

Date the referral is being made.

Referral Source (required)

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 (required)

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)

Required acknowledgment before submitting a confidential referral.

Yes No N/A

Employee Information

Employee Name (required)

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 (required)

Select the main reason for the referral.

If other, describe the concern

Brief Summary of Concern (required)

Provide a concise, factual summary. Avoid unnecessary personal details.

Observed Impact on Work

Select any observed work-related impacts.

Urgency Level (required)

Choose the level of urgency based on current circumstances.

Risk, Consent, and Accommodation

Is there an immediate safety risk requiring urgent intervention? (required)

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 (required)

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 (required)

Select all resources that were provided or discussed.

Follow-Up Owner (required)

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 (required)

Document the agreed next steps, including any outreach, check-in, or referral actions.

Submitter Signature

Optional signature for internal audit trail or acknowledgment.

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Email (required)

Your name (optional)

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