WFD Support Service Request (Non-Financial)
Employee Assistance Referral Form
Team Member
*
First Name
Last Name
Job Title
*
What is your current position?
Email Address
user@youremail.com
Phone Number
*
-
Area Code
Phone Number
Location
*
529
Alvin
Atascocita
Baytown
Brenham
Briargrove
Champions
City Centre
Clear Lake
Conroe
Crosby
Cypress Outlet
eCommerce
Fairfield
Fairmont
Galveston
Gessner Computer Works
Gessner Outlet
Grant @ Louetta
Greatwood
Greenspoint Outlet
Heights
Humble
Huntsville
Hwy 6 @ Voss
I-10
Jones Road
Katy Kingsland
Katy Ranch
Kuykendahl @ Louetta
Lake Jackson
La Porte
Long Point Outlet
Longmeadow
Meyerland
Missouri City
Nasa
Pearland Plaza
Piney Point
Porter
Reading Rd
River Oaks
Sabo Outlet
Sealy
Spring
Telfair
Tomball
Victory Lakes
West Oaks
Willis
Willowchase
Wilson Road
Woodlands
ADC - Cinco Ranch
ADC - College Park
ADC - Cross Creek
ADC - Cypresswood
ADC - DA/Memorial
ADC - Deer Park
ADC - Ella & 43rd
ADC - Friendswood
ADC - Gleannloch
ADC - Gosling
ADC - Kingsley Crossing
ADC - Kirby
ADC - Lakeshore
ADC - Lexington
ADC - Louetta
ADC - Magnolia
ADC - Mason Road
ADC - Medical Center
ADC - Meyerland
ADC - Morton Ranch
ADC - North Park
ADC - Rayford
ADC - River Oaks
ADC - Riverstone
ADC - Saddlebrook
ADC - Shepherd
ADC - Silverlake
ADC - South Shore
ADC - Stella Link
ADC - Sugar Creek
ADC - Tuscan Lakes
ADC - W. Alabama
ADC - West Road
ADC - Wirt
ADC - Woodway
1140 Corporate
Heights JC
Meyerland JC
River Oaks JC
Galveston JC
Do Not Know or Unsure
What location do you work at?
Are you a manager submitting on behalf of an employee?
Yes
No
Referring Manager (If Applicable)
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email Address
Your email address
Referral Date
*
/
Month
/
Day
Year
Date
Pre-Referral Check - Have the following been completed?
*
New Hire Training Completed
90 Day Probationary Period Completed
HR Business Partner Contacted
Does the Team Member have an assigned Job Coach
Yes
No
Unsure
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?
Yes
No
Job Related Request
Work Assessments
Job Coaching/Soft Skills
Career Development
Skills Training
Other
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
Support Service Request
Transportation
Housing
Food Insecurity
Utility Bills
Furniture
Clothing
Childcare
Financial
High School/GED
Medical Assistance
Legal Assistance
Mental Health
Substance Abuse
Funeral Services
Tax Service
Other
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
Submit
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