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Run: 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 su...

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Referral Details

Referral Date (required)

Date the referral is being submitted.

Referral Source (required)

Who is making the referral?

If other, specify referral source

Employee Department

Department helps route the referral without collecting unnecessary PII.

Work Location

Optional. Include only if location is needed for local support coordination.

Confidentiality acknowledgment (required)

I understand this form may contain sensitive PII and will be handled confidentially by authorized personnel only.

Yes No N/A

Concern and Referral Reason

Primary concern (required)

Select the main reason for referral.

If other, describe the concern category

Brief summary of concern (required)

Provide a concise summary of the issue and its impact. Avoid unnecessary personal details.

How long has this concern been present?

Observed work impact

Select all that apply.

If other, describe observed work impact

Risk, Accommodation, and Immediate Support

Is there an immediate safety risk? (required)

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

Is a workplace accommodation being requested? (required)

Use this to identify whether ADA reasonable-accommodation follow-up may be needed.

Accommodation details

Urgent support requested

Check if the employee needs same-day contact or expedited follow-up.

Yes No N/A

Consent and Disclosure

Employee consent to refer to EAP (required)

The employee consents to this referral and understands that information will be shared only with authorized support personnel as needed.

Yes No N/A

Information sharing acknowledgment (required)

I understand that only the minimum necessary information will be shared to coordinate support.

Yes No N/A

Preferred contact method (required)

Contact preferences or restrictions

Include preferred times, accessibility needs, or contact restrictions.

Resources and Follow-Up

Resources offered

Select all resources that were offered or discussed.

If other, specify resource offered

Follow-up owner (required)

Follow-up date

Date for the next check-in or review.

Follow-up actions

Document the next steps, including any referrals made and any action items.

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Email (required)

Your name (optional)

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