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Employee Assistance Programme – Self Referral Form
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Employee Assistance Programme (EAP) – Self Referral Form
Section A: Employee Details
Full Name
Staff Number
Department
Contact Number
Email Address
Section B: Reason for Referral
Reason(s)
Workplace Stress / Burnout
Workplace Conflict
Mental Health Concerns
Other
Other Reason
Section C: Support Requested
Support Requested
Stress Management Support
Counseling
Workplace Mediation
Other
Other Support
Section D: Declaration & Consent
I confirm the details provided are accurate and consent to this referral.
Date
Submit Form
