Employee consent form for voluntary self-referral to an Employee Assistance Program (EAP), authorizing the EAP provider to contact the employee and, where applicable, to share limited status information with the employer for administrative purposes only. Clearly delineates confidentiality protections.
The EAP Self-Referral Consent is a ready-to-use records & authorization template you can send for signature in minutes. It is written for 1 signer (employee) and, by default, expires 14 days after it is sent if left unsigned. It covers eap, employee assistance, mental health, confidentiality, self referral, consent. Like every Abundera Sign template it is a convenience draft structured for ESIGN Act and UETA compliance, not a substitute for legal advice. Each signed copy is sealed with PAdES-LTA digital signatures, dual RFC 3161 timestamps, and a tamper-evident evidence package in WORM storage.
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# EAP Self-Referral Consent --- ## About This Form This form authorizes your employer to refer you to the Employee Assistance Program (EAP) and, where you choose to allow it, to receive limited administrative information from the EAP for purposes described below. Participation in the EAP is voluntary and confidential. Using EAP services will not affect your employment status, salary, benefits, or job security. This form is kept separately from your personnel file. --- ## Employer / EAP Information **Employer / Company Name:** ___________ **EAP Provider Name:** ___________ **EAP Provider Phone Number:** ___________ **EAP Provider Website:** ___________ **Number of Sessions Covered Per Issue Per Year:** ___________ **HR or EAP Program Contact at Employer:** ___________ **HR EAP Contact Phone:** ___________ --- ## Employee Information **Employee Full Name:** ___________ **Employee ID:** ___________ **Department:** ___________ **Job Title:** ___________ **Work Phone / Extension:** ___________