For HR & people teams

Organisation HR referral form

Use this form to refer an employee to APS for wellness support. All referrals are handled with strict confidentiality in line with NDPR.

Submit Referral

Note: This form does NOT replace emergency services. For crisis, call 112.

NDPR Compliant. We are an independent provider. HR will not receive session details.

HR / organisation details

1. Organisation name

2. HR contact person

3. HR email

4. HR phone

5. Company size

Employee details — confidential

Only provide details you have consent to share. We will contact the employee directly.

6. Employee full name

7. Employee email

8. Employee phone

9. Employee department / role

10. Preferred mode of session

In-person

Online

No Preference

Reason for referral

This helps us match the right therapist. All information is confidential.

Support & consent

15. Has the employee been offered EAP before?

Yes

16. Urgency level

Routine - within 2 weeks

Priority - within 1 week

Urgent - within 48hrs

17. Any workplace accommodations needed?

18. NDPR + consent

I confirm I have consent from the employee to share their contact details OR our company policy allows referral for wellbeing support. *I understand APS will contact the employee directly and maintain therapist-client confidentiality. *I understand that session content will NOT be shared with HR except with written employee consent or risk of harm. *

Signature — type your full name

Date

Support not discipline. Referrals are stored securely under the NDPR.