Monitored EAP referral
The fields identified by a star (*) are mandatory.
Employee/Team Member
Employer
First name
*
Organization
*
Last name
*
First name of the designated contact person
*
Home phone
Last name of the designated contact person
*
Work phone
Phone
*
Mobile phone
Email
*
Best time to reach the employee
*
Reason(s) for the EAP referral
*
Birthdate
---
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
---
January
February
March
April
May
June
July
August
September
October
November
December
---
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
If you have already referred the employee to the EAP, please specify the date of the referral
---
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
---
January
February
March
April
May
June
July
August
September
October
November
December
---
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
Position
Is the employee’s continued employment conditional to participation in EAP services?
*
Yes
No
This field is mandatory
Employed since (year)
*
This field is mandatory
The designated contact person will receive an account of the employee’s participation, collaboration and progress, in full compliance with privacy legislation. This account will be available verbally or by email, monthly or at the end of the process. Please specify the desired format and frequency
*
Is the employee absent from work?
*
Yes
No
This field is mandatory
--- Select ---
By email
Verbally
This field is mandatory
--- Select ---
At the end of the process
Monthly
This field is mandatory
Please attach the authorization form to contact the employer, duly signed by the employee
Select a file...
Select a file...
Select a file...
The sum of all files must be lower than 30 MB
Additional information
Please add any other information relevant to the understanding of the issue and the management of the case.
We are processing your request. Please wait.