Employee Counseling Referral
This benefit was created to support the health and wholeness of our staff when counseling is the appropriate next step in a holistic approach to care. We view this as a meaningful investment in our team. While we strive to care for all staff equitably, this benefit is not guaranteed beyond what is outlined in this document. The executive team reserves the right to adjust or discontinue the benefit if deemed necessary.
Your Name
*
First Name
Last Name
Your Email
*
example@example.com
Employees Name
*
First Name
Last Name
Employees Email
*
example@example.com
Referring Pastor's Name (if supervisor is not a pastor)
First Name
Last Name
Pastor's Email
example@example.com
Have you had the conversation with your employee about this benefit and they are aware you are referring them?
Yes
No
Back
Next
Save
Counselors information
Counselors Name
*
First Name
Last Name
Counselors Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Is this counselor is on the approved list?
Yes
No
Supervisor Signature
Save
Submit
Submit
Should be Empty: