Office Of Human Resources
Employee Assistance
Program
EAC Counseling Referral Form

 


TO:

FROM:

RE: REFERRAL FOR COUNSELING WITH THE EMPLOYEE ASSISTANCE PROGRAM

DATE:

Employees Name:


Title: _______________________________
Department: ______________________________________________ Phone No. ___________________________
Supervisor's Name: ________________________________________ Phone No. ___________________________
Employee's Days Off: ______________________________________ Shift: _______________________________

The above named employee is being referred to the Employee Advisory Service for counseling for the following reasons: (Please be specific regarding the reason for referral. If necessary, you may attach pertinent supporting documentation, ie. letters of counseling, PAR's, significant events, etc.).











EMPLOYEE HAS BEEN ADVISED OF THIS REFERRAL
YES __________

NO __________

NOTE: An employee needs to be advised that a referral for counseling is being made in order for an appointment to be scheduled. Without the information from the supervisor, the EAP counselor only hears one side of the story - the emplyees. Your information is crucial in being able to resolve the problem..

12/99