Referral Form
Confidential Form: This form is used for referring employees to the Employee Assistance Program.
Instead of using the online form, you may print this form (pdf) and fax to the EAP: 843-792- 7298.
Please feel free to call 843-792-2848 to talk with an EAP therapist concerning supervisory issues. Phone consults are encouraged.


Name of Employee:
Referral Date:
Job Title:
Employee Phone Number:
Referral Request By:Supervisor's name
Supervisor's Title:
Supervisor's Phone:
Supervisor's Email:
Division/Department:

Reason for Referral: Please indicate the reasons warranting the employer's referral to the EAP:

Absenteeism
Frequent sick leave or illness on the job
Extended lunch periods or breaks
Early departures
Unusual excuses for absences
Frequently leaves work place
Multiple instances of unauthorized leave
Excessive lateness
Excessive absenteeism
Other
Please describe the problem, any patterns observed, frequency of lateness and/or number of absences in past 12 months:


Job Performance
Lower quality of work
Frequent accidents on the job
Erratic work pattern
Failure to meet schedules
Increased errors
Impaired judgement, memory, ability to concentrate
Decreased productivity (or alternating periods of increase and decrease)
Other
Please describe the problem, any patterns observed, and frequency in past 12 months:


Desired Improvement: What must the employee do to achieve satisfactory performance?
Please be specific and include a time frame for improvements:




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