Employee Counseling Service Referral Form
Use this form to refer an employee for counseling services. Please provide accurate and complete information to facilitate appropriate support.
Employee Full Name
*
First Name
Last Name
Employee Email Address
*
example@example.com
Employee Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Employee Department/Unit
*
Please Select
Human Resources
Finance
Operations
Sales
IT
Marketing
Other
Employee Job Title/Position
Referrer's Full Name
*
First Name
Last Name
Referrer's Email Address
*
example@example.com
Relationship to Employee
*
Please Select
Direct Supervisor
HR Representative
Manager
Colleague
Other
Reason for Referral
*
Type of Counseling/Support Needed
*
Stress Management
Conflict Resolution
Work Performance Issues
Personal Issues Affecting Work
Substance Use Concerns
Other
Has the employee previously participated in counseling services?
Yes
No
Unknown
Urgency of Referral
*
Routine
Moderate
Urgent
Additional Comments or Relevant Information
Date of Referral
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Referrer's Signature (draw your signature below)
*
Submit Referral
Submit Referral
Should be Empty: