EVIDENCE-BASED PRACTICE. CLIENT-CANTERED PROGRESS
MERIDIAN WELLNESS SOLUTIONS
Registration No (CIPC): 2021/777546/07
SACSSP Reg No: 1033525 | BHF Practice No: 0966304
Email:
meridianwellnessSA@yahoo.com
EMPLOYEE ASSISTANCE PROGRAMME (EWP) REFERRAL FORM
(To be completed by HR Managers, Supervisors, or EWP Leads)
1. CORPORATE REFERRAL SOURCE
Company / Organisation Name:
Referring Manager / HR Representative:
Department / Designation:
Direct Contact Number:
Email:
example@example.com
2. EMPLOYEE DETAILS
Employee Full Name & Surname:
Job Title / Department:
Length of Service / Employment Duration:
3. NATURE OF WORKPLACE REFERRAL (PLEASE TICK ONE)
Nature of Workplace Referral
Voluntary Referral: The employee requested support independently.
Formal Supervisory Referral: Prompted by observed drops in workplace output or friction.
Mandatory Disciplinary Referral: Part of a formal corrective action/disciplinary framework.
4. CORE WORKPLACE OBSERVATIONS (TICK ALL THAT APPLY)
Core Workplace Observations
Visible, sudden drop in daily work performance / missed deadlines
High rates of absenteeism, unexcused leave, or chronic tardiness
Emotional outbursts, insubordination, or interpersonal conflict with colleagues
Suspected substance / alcohol misuse impacting operational safety
Exposure to acute workplace trauma, grief, or operational distress
Briefly describe the specific workplace incidents or performance issues prompting this referral:
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EVIDENCE-BASED PRACTICE. CLIENT-CANTERED PROGRESS
5. EMPLOYER CONFIDENTIALITY ACKNOWLEDGEMENT
[ ] (Initial) I understand that due to statutory confidentiality and POPIA rules, Meridian Wellness Solutions can only confirm to the employer whether the employee attended the sessions and general fitness for duty. No specific clinical details will be disclosed without explicit, written employee consent.
Signature of HR / Manager/ Supervisor
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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