Substance Abuse Professional (SAP) Referral Form
This referral is for an employee who is in violation of your Alcohol and Drug Policy, or has self-disclosed an issue with substance use that warrants an assessment by a Substance Abuse Professional. The process for the SAP Assessment involves an initial assessment of the employee with our clinician, after which a report will be created and forwarded to the Designated Employer Representative (DER) noted below. The employee will return for a follow-up assessment after completing recommended treatment.
Please ensure that the SAP process has been explained to the referred employee. Please note the employee will sign a Release of Information at the initial appointment noting consent to have appropriate information released to the DER. If you are referring to another program or have additional questions please contact our office at 888-617-2279 or at firstname.lastname@example.org
Employee Last Name (required)
Employee First Name (required)
Employee Date of Birth (required)
City/town client will attend appointments (required)
Employee Telephone (required)
Massages OK? (required)
Employee e-mail (required)
Designated Employee Representative (DER) Name (required)
DER Title and Company (required)
DER email (required)
DER Telephone (required)
Is this a referral for a DOT SAP assessment? (required)
Additional details; please include dates of failed tests, substances involved, and any relevant information about this referral.