EAP Referral | Positive Innovations

EAP Supervisor Referral

Company

Employee Name

Employee Birthdate

Phone

Other concerns:

Type of referral to EAP:

Informal- The employee is encouraged to contact EAP for advice in identifying strategies in resolving the stated job performance concerns.

Formal-The employee is requested to contact the EAP by (select date below) and comply with the recommendations. The employee is expected to satisfy the on the job improvements that have been identified and their involvement with EAP does not protect the employee from disciplinary action. The employer will receive feedback on appointment and compliance status.

Mandatory-The employee is required to contact the EAP by (select date below) and comply with the recommendations or face further discipline. The employee is expected to satisfy the on the job improvements that have been identified and their involvement with EAP does not protect the employee from disciplinary action. The employer will receive feedback on appointment and compliance status.

Deadline to contact EAP:

Supervisor Name

Title/ Position

Supervisor Phone

Supervisor Email

Supervisor’s Statement of Intent:

I understand the purpose of the EAP referral, is to allow the employee the opportunity to seek objective, professional assistance towards resolving documented job performance concerns. I endorse the employee’s use of the EAP and will support the employee’s ongoing treatment as recommended by the EAP. I will provide direct, objective, and timely feedback related to the employee's job performance.

Supervisor Signature

I decline the offer and/ or referral to EAP.

I understand that my signature on this form and Disclosure of Health Information is necessary for Positive Innovations to share the following information. The Authorization for Disclosure of Health Information is usually completed during the first meeting with the counselor. In the absence of the forms completed, Positive Innovations cannot share whether you made/ kept an appointment at EAP. The following information can be shared once you sign the release: 1. Date that the employee contacted the EAP. 2. Participation or non-participation in the recommended plan of action. 3. Continuation or discontinuation in recommended plan of action.

Employee Signature: I acknowledge and accept the terms of this EAP referral.

Your referral was submitted successfully. Your employee will be contacted to schedule an appointment or feel free to contact the office nearest you.