Cigna
EmployeeAssistance
Program
1.877.622.4327
EmployerID:COR
CignaBehavioral.com
CITYOFRICHMOND
DepartmentofHuman
Resources
900
E.BroadStreet,Room902
Richmond,VA23219
(804)6465660
FAX6466856
Revised January 19, 2017
ManagementReferralForm
Date:
To:
HR Consultant, Department of Human Resources
From:
Referring Supervisor
Department Phone Number
Re:
Employee Full Name
The employee listed above is being formally referred to the EAP for assistance with:
A pattern of performance problems
A pattern of behavior problems
Violation of the Alcohol Section of the Substance Abuse Policy- Confirmed alcohol test
of >0.02 and <0.04
Other (please specify):
Special Notes to Supervisors:
Email or fax this form to your HR Consultant and follow up by phone for approval.
Once you receive approval from the HR Consultant for a management referral, call
Cigna at 1.877.622.4327 and use the Employer ID: COR
If you have supporting documentation related to this referral, please provide it to the HR
Consultant.
Copies of this form should be forwarded to the department HR Liaison and the employee.
Approved/Disapproved: ___________________________ Date:
cc: Personnel File
Print Form
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