Employee Assistance Program Referral Request

Employee Assistance Program Referral Request — Form Fields

This hr template includes 8 fields. Manager or employee requests a confidential EAP referral for mental health or personal support. Free to customize and use on ZenBuild.

• Requestor Name (text, required)
• Requestor Type (dropdown selection, required) — options: Self-referral, Manager referral, HR referral
• Employee Name (if manager/HR referral) (text, optional)
• Department (text, required)
• Type of Support Needed (dropdown selection, required) — options: Mental health, Financial counseling, Substance abuse, Family issues, Legal assistance, Other
• Brief situation description (confidential) (long text, optional)
• Is this urgent? (multiple choice, required) — options: Yes, No
• Preferred Contact Method (text, optional)