WFD Support Service Request (Non-Financial)

WFD Support Service Request (Non-Financial)

Employee Assistance Referral Form
Team Member*

First NameLast Name
Job Title*
What is your current position?
Email Address
user@youremail.com
Phone Number*

Area CodePhone Number
Location*
What location do you work at?
Are you a manager submitting on behalf of an employee?

YesNo
Referring Manager (If Applicable)*

First NameLast Name
Phone Number*

Area CodePhone Number
Email Address
Your email address
Referral Date*

MonthDayYear
Date
Pre-Referral Check - Have the following been completed?*

New Hire Training Completed90 Day Probationary Period CompletedHR Business Partner Contacted
Does the Team Member have an assigned Job Coach

YesNoUnsure
Job Coaches Name?
What is the name of the Job Coach
Who is your Supervisor?
What is your supervisor's name?
Do you have a Job Coach?
If so, please type their name here.
Have you been affected by COVID 19?
Job Related Request

Work AssessmentsJob Coaching/Soft SkillsCareer DevelopmentSkills TrainingOther
Describe the employee ability to perform functions of current job role. Describe any behaviors that have been labeled as challenging. Are there any factors that need support to maintain production standards?
After observing the employee, describe the employee ability to perform assigned tasks and duties. Are there any factors noted for which support may be needed?
Are there any strategies that appear to work for managing behavior?
Summary of employee’s functional limitations, challenges and barriers observed during observation.
Describe all accommodations, compensatory techniques and special training needs required by the employee.
Recommendations to improve or enhance future skills and performance.
Additional Comments.
Specify most immediate needs
I understand that requesting these services, does not mean that Goodwill can directly provide these services as we are not an emergency or relief organization. I also understand that requesting for resources, information, and or referrals takes time, and the team works with other organizations that work typically within business hours.*

I agree
Should be Empty: