FROM: Name of Administrator
RE: Employee Assistance Program
We have made an appointment for you with the Employee Assistance Program for an
Your appointment is with (name of doctor), on (day and date) at (time). His office is located
You are required to sign and date the attached permission form for the release of medical
information to Mr. Berry in Human Resources. Please rest assured that any medical
information released will be held in the strictest confidence.
Please understand that we are concerned about your health and continued employment with
the District. We would like to make available to you any of the services that the district can
provide for your assistance.
Failure to attend this appointment could result in a disciplinary action against you.
Attachment – Medical Release Form
o: Leroy A. Berry – Deputy Superintendent
c: Joy A. Salamone – Director, Labor Relations
This is to confirm that a copy of the original of this document was provided to me on (Date)
by (Name and Title of Administrator).
My signature merely signifies receipt of this document and does not necessarily indicate
agreement with its contents.
Employee’s Signature Date
EMPLOYEE ASSISTANCE PROGRAM (EAP)
SUPERVISORY REFERRAL ONLY
(please type or print legibly)
Employee Name: _________________________________ Social Security: _______________
Provider Name: ________________________________________________________________
(Psychiatrist, Psychologist or Counselor)
AUTHORIZATION TO RELEASE INFORMATION
If my employer formally referred me to the Employee Assistance Program (EAP), I hereby
authorize The Bradman Network to release information pertaining ONLY in accordance with
the following authorization.
My EAP counselor is authorized to release to my employer any information he/she deems
Employee’s Signature: ___________________________________ Date: ________________
Mr. Leroy A. Berry, Deputy Superintendent
School Board of Brevard County, Florida
2700 Judge Fran Jamieson Way
Viera, Florida 32940-6699