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Contact us for any questions or inquiries — we’ve got you covered!

Feel free to reach out to us using the form below. One of our experienced team members will follow up with you soon!

Foundations EAP Program

Submit A Referral

Employee Referral

HR Representative Information

Representative Name *

Title *

Contact Number *

Email *

Date of Referral

Employee Information

Employee Name *

Job Title *

Department *

Contact Number *

Email *

Reason for Referral

Type of Referral *

Voluntary (Employee requested assistance)

Supervisory/HR Referral (Management recommended services)

Mandatory (Condition of continued employment or return to work)

Is the employee in immediate danger of harming him/herself or someone else? *

Yes

What is the reason for the referral? *

Job performance concerns (absenteeism, tardiness, productivity)

Workplace behavior or conflict

Emotional distress or mood changes

Stress management

Substance use concerns

Family or relationship concerns

Grief or loss

Financial or legal stress

Health or wellness issues

Other

Please explain the reason briefly

Comments / Additional Information about the referral:

I understand that participation in services is voluntary and confidential unless disclosure is required by law or deemed necessary to ensure workplace safety.

By signing below, I acknowledge that I have been informed of this referral and have received information about available services.

Authorization and Confidentiality *

Clear

If you are human, leave this field blank.

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(803) 233-4447

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(803) 832-2292

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