EAP Referral Form EAP Referral Form "*" indicates required fields URLThis field is for validation purposes and should be left unchanged.Referrer Details Organisation*Referrer's Name*PositionPhone*Email* Employee DetailsName* First Last Date of Birth Job TitleWork LocationPhone*Email*Preferred Contact MethodPreferred Days/Times for ContactReason for Referral*Is the employee aware of this referral? Yes No Has the employee consented to Recovery Partners contacting them?* Yes No Is this referral urgent?* Yes No If yes, please provide details below.Are there any known risks or safety concerns?*Treating DoctorDoctor's NamePracticePhone NumberPlease provide any additional information that may assist our clinician in making initial contact with the employee.Consent* I confirm that the employee has consented to this referral (where applicable) and that the information provided is accurate to the best of my knowledge.Recovery Partners will use the information collected in this form solely for the purpose of coordinating Employee Assistance Program services. Personal information will be handled in accordance with applicable privacy legislation. Information disclosed during counselling sessions remains confidential except where disclosure is required by law or where there is a serious and imminent risk of harm.Please note: The Employee Assistance Program is not an emergency or crisis service. If the employee requires immediate support or there is an immediate risk to their safety or the safety of others, please contact 000 (if there is an emergency) or attend the nearest hospital emergency department. For immediate mental health support, contact Lifeline on 13 11 14 or 13YARN on 13 92 76 for culturally safe crisis support for Aboriginal and Torres Strait Islander peoples.
