Early Intervention Service (EIS)

Referral Form

EIS Referral Form

Thank you for taking the time to consider our Early Intervention Services. Our in-house team are here to help. To enable them to contact your employee, please complete the referral form below. Please ensure your employee is aware of the referral before submitting.

Employer Details

If there has been recent Occupational Health involvement the nurse may contact you to discuss this further

Employee Details

The information you have provided in this form will be used in accordance with our data protection notice. A copy of this notice can be found here Data protection notice | Canada Life UK

Fields marked with an * are mandatory and must be filled in before submitting the form.