Wellness Referral Form

Self Referral

Other

(If this is not a self-referral, please ensure the employee is aware of this referral.)

Sick Leave or Short-term Disability - exceeding 5 days (Complete ALL sections below)

Medical Accommodations (Employee still at work)

Excessive Absenteesim Due to Medical Reasons

Other

If sick leave or short-term disability

If absence exceeds 5 days

Can be found on your paycheque

Female

Male

Gender Variant

Prefer not to say

ASPA

Exempt

Non-union Employees

USFA

Other

CUPE 1975

Full Time

Part Time

Permanent

Temporary

If temporary, start and end date

ConnectionPoint

Other

Yes

No

Unknown