Management Referral Form - Direction For Employee Assistance

DIRECTION

for Employee Assistance

2650 Suzanne Way , Suite 120

Eugene, OR 97408

Phone: 541-345-2800

FAX: 541-345-4419

MANAGEMENT REFERRAL FORM

Employee Name: _______________________

Phone #____________________________

Job Title: ______________________________

Company: __________________________

I understand that I am being formally referred to DIRECTION for Employee Assistance for assistance to resolve job

performance, conduct or safety related problem behavior. My supervisor and/or Human Resources reviewed the job

performance problem behaviors with me as noted on the second page of this document.

I hereby authorize DIRECTION EAP to release information verifying my contact and participation in the EAP and

adherence with the recommended treatment plan. I understand that this is a limited release of information to disclose

participation in the EAP assessment, treatment plan, adherence with treatment, and for my supervisor/HR to disclose information

about job performance with DIRECTION.

DIRECTION EAP will take appropriate legal and ethical precautions to protect the confidentiality of my discussions with my

counselor and that any information exchanged between my counselor/s and my employer will be limited to clinical

information relevant and necessary to an effective resolution of this job-performance situation.

_____________________________________________________ ____________________________

EMPLOYEE’S SIGNATURE

DATE

A copy of both pages of this fully signed referral given to the employee: ___Yes

___No

For referring Supervisor and/or Human Resources:

I have discussed the job performance problem behavior(s) and initiated a formal management referral to EAP.

____________________________

______________

_______________________

Print Supervisor’s Name

Date

Phone #

____________________________

______________

_______________________

Print Human Resource Name

Date

Phone #

____________________________

Print name of person for DIRECTION

Fax #: _________________

Confidential fax? Yes___ No ___

to contact.

Please have employee call DIRECTION to schedule initial appointment.

Date first EAP appointment must be scheduled by: ________________________

This information has been disclosed to you from records whose confidentiality is protected by federal law. Federal regulation s (42 CFR, part 2) prohibit you

from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by such

regulation. A general authorization for the release of medical or other information is not sufficient for this purpose. The federal rules restrict any use of the

information to criminally investigate or prosecute any alcohol or drug abuse patient.

Fax this completed form to DIRECTION (541-345-4419) prior to the initial EAP assessment

Call DIRECTION with any questions about the referral procedures

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