Formal Supervisor Referrals—Performance

1. Call The Village EAP before beginning the referral process at 1-800-627-8220. Ask to speak to an EAP staff member regarding a supervisory referral. View a graphic representation of the referral process.
2. Open and print the Performance referral form or the Drug-Free Workplace/D.O.T. form.
3. Complete the top section of the form with the identifying information requested. Include the date of last employee performance evaluation.
4. Complete the section “REASON FOR REFERRAL” which describes the employee’s job performance issues that led to the referral. Include as much information as possible to help our professionals understand the work problem in question.
5. In the section “ADDITIONAL COMMENTS BY REFERRING SUPERVISOR” please document all discussions with the employee regarding the referral issue. It is very important to include information regarding the employee’s current status with the company. Include conditions for continued employment, such as the time frame in which you expect to see improvement, and any pending disciplinary action. Attach additional comments if necessary and copies of any relevant documentation (memos to the employee, written warnings, specific policy violations, etc.) which may be helpful to make the counselor aware of the issues at hand and specific performance goals for the employee.
6. In the section "EMPLOYEE SIGNATURE AND RELEASE OF INFORMATION," have the employee print their name where directed, and sign and date the form in the appropriate blanks. The signature serves as a release of information regarding EAP use and indicates the employee’s understanding of your concerns. Sign your name where indicated (“Supervisor Signature”). Fax the completed form to The Village EAP for processing. Our fax number is (701) 451-5058. Upon receipt of the completed form, Village EAP staff will also sign the form.
7. The employee is then responsible for contacting The Village EAP to schedule the initial appointment.
8. We will notify you in writing about the status of the referral and the employee’s compliance with treatment recommendations. No other information will be released to you without the employee’s written consent.