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

If you have already referred the employee to the EAP, please specify the date of the referral

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

This field is mandatory
This field is mandatory

Please attach the authorization form to contact the employer, duly signed by the employee

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The sum of all files must be lower than 30 MB

Additional information

Monitored EAP referral

Please attach the authorization form to contact the employer, duly signed by the employee

Please add any other information relevant to the understanding of the issue and the management of the case.

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