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Referral Process

Leader Referral Form



Person making referral:*
Position:*
Phone:*
Pager:
Employee being referred:*
Phone:*
Position:*
Market:*

Briefly state the employee's job performance problem(s) and reason for referral:
 

What are your expectations for change from the employee?
 

Date leader met with employee:*
Date of referral to EAP:*




Select the name of the counselor you discussed this employee with:*