Employee Assistance Programme (EAP) – Peer Referral Form

Employee Name

Employee Number

Department / Faculty

Contact Number

Email Address

Referring Peer Name

Relationship

Contact Number

Date of Referral

Reason(s)

Stress or Burnout

Workplace Conflict

Mental Health Concerns (e.g., anxiety, depression)

Substance Use / Alcohol Concerns

Bereavement / Grief

Relationship / Family Difficulties

Financial Stress

Other

If Other

Description

I have discussed this referral with the employee, and they have agreed to be referred to the EAP.

Date

Employee has been informed that this referral is confidential and voluntary.

Date

13 Jackson Kaujeua Street Windhoek West Windhoek