EMPLOYEE ASSISTANCE PROGRAMa component of

Live Well/Work Well

Dartmouth-Hitchcock Medical Center1 Medical Center Drive

Lebanon, NH 03756-0001Phone (603) 650-5819

Fax (603) 650-5788www.dhmc.org/goto/EAP

SUPERVISORY REFERRAL FORM

Name of Supervisee:

Date:

Kind of referral (please check one):I have suggested the Employee Assistance Program (EAP) to the supervisee.I have “strongly recommended” the EAP to the supervisee because of job performance problems and I have documented this recommendation.

Brief description of the problem:

Yes No Have there been disciplinary actions related to this referral? If so, please describe:

Yes No Are you requesting verification that the supervisee made contact with the EAP and attended at least an initial appointment?

Please note: If you request verification and do not hear from the EAP after your referral, it means one of two things has happened: either 1) the supervisee did NOT contact the EAP and/or did NOT arrive for a scheduled appointment; or 2) s/he refused to sign a release of information authorization that would allow EAP to communicate with you. In either case, it is entirely appropriate—and actually a good idea—for you to follow-up with the supervisee. You might ask something like, “Were you able to reach the EAP and get an appointment?” Whatever the response, you will obtain information that will help you in your role as supervisor.

Your name:

Title:

Department:

Phone number/pager:

Email address:

Thank you for providing this information.

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Dartmouth-Hitchcock Clinic | Mary Hitchcock Memorial Hospital | Dartmouth Medical School | V.A. Medical Center, White River Junction,VT