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

Policy/Scheme name ^*(This is usually the employers name)

Policy number

Name of person making referral ^*

Email address of person making referral ^*

Contact telephone number of person making referral ^*

What are you looking to achieve from the referral? ^*

Has there been any Occupational Health involvement? ^* If there has been recent Occupational Health involvement the nurse may contact you to discuss this further

If so, when was this? ^*

Can reasonable adjustments such as home working, lighter duties and a phased return be accommodated? ^*

Working from home

Lighter duties

Phased return inc reduced hours

Alternative tasks

Other adjustments (to be discussed)

When is a good time to contact the employee?

Employee Details

Employee’s name ^*

Telephone number for the employee ^*

Date of birth ^*

Date of joining the organisation ^*

Job title ^*

Type of work undertaken

Is the employee currently absent?^*

What is the medical reason for referral? ^*

Employee email address

Would you like to speak with a member of the team?^*

Any other information to provide

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

I confirm I have read the Data Protection Notice and agree to Canada Life using, processing and sharing my personal data provided for the purposes set out in the Data Protection Notice. I understand how Canada Life will use the personal data of the employee (including special categories of personal data) in line with the Data Protection Notice.

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