Employee Assistance Programme – Supervisor Referral Form

Employee Assistance Programme (EAP) - Supervisor Referral Form

Employee Name

Staff Number

Department

Contact Number

Supervisor Name

Position

Contact Number

Email

Reason(s)

Decline in Work Performance

Frequent Absenteeism / Tardiness

Noticeable Behavioural Changes

Emotional Distress / Mood Changes

Interpersonal Conflict at Work

Other

If Other

Discussion Status

I have discussed the referral with the employee.

The employee understands and has consented to this referral.

Observed Concerns

I confirm that this referral is made in a supportive manner and not for disciplinary purposes.

Date

I acknowledge that I have been informed of this referral to the EAP and consent to participate.

Date

13 Jackson Kaujeua Street Windhoek West Windhoek