Employee Assistance Program (EAP)
Substance Abuse Referral Form
Employee Name
Employee ID
Department
Position
Supervisor Name
Date of Referral
Reason for Referral / Observed Concerns
Date(s) of Incident(s) (if applicable)
Actions Taken Prior to Referral
Employee Acknowledgement
Employee Signature
Date
Supervisor/Manager Information
Supervisor/Manager Signature
Date