Kaelo Lifestyle Formal Referral

Your Kaelo Lifestyle Plan *

Kaelo Lifestyle | AskNelson

Kaelo Lifestyle | Digital

Kaelo Lifestyle International

When one of your employees requires assistance, you can either formally or informally refer them to the AskNelson Programme:

Informal Referral
When you are concerned about an employee who is going through a difficult time, you can remind them that the AskNelson Programme offers free and confidential assistance. No information is released to the manager about attendance or participation. No forms are necessary!
The employee can simply call 0800 635 766 and speak to a counsellor immediately.

Formal Referral
A formal referral to AskNelson is appropriate when dealing with challenges related to the work performance of an employee. Rest assured that by following the steps below, help is on the way!

1. Consult with the employee regarding the reason for the referral. There should be a consensus between the referring manager and the employee regarding:
a) The impact of the presenting problem on work performance
b) Agreement on the desired outcomes
2. Complete the AskNelson Formal Referral Consent form.
Once completed, the form should be reviewed with the employee and signed.
3. Complete online or email the signed and fully completed consent form to asknelson@www.kaelo.co.za.
4. An AskNelson Managerial Consultant will establish contact with the referring manager and the employee within 8 working hours of receipt of the referral form to conduct:
a) A managerial assessment with the referring manager, and
b) A clinical assessment with the employee.
5. AskNelson is committed to providing timely feedback and the referring manager can expect interim feedback subsequent to the initial assessment with the employee and a final feedback report upon completion of the formal referral process.

The AskNelson formal referral is a tool used by managers to document work challenges related to the performance or conduct of an employee. In order for the AskNelson team to facilitate the process, we require as much information as possible, to give us insight into the challenges at hand. Please complete the document in as much detail as possible.

The employee is required to sign the consent form in order for the AskNelson team to provide the referring manager with progress feedback. Where an employee does not sign the consent form, no feedback will be provided. The formal referral is a voluntary process and employees cannot be forced to sign the consent form.

When one of your employees requires assistance, you can either formally or informally refer them to the Kaelo Lifestyle International Programme:

Informal Referral
When you are concerned about an employee who is going through a difficult time, you can remind them that the Kaelo Lifestyle International Programme offers free and confidential assistance. No information is released to the manager about attendance or participation. No forms are necessary!

The employee can simply call +27 11 759 9609 and speak to a counsellor immediately.

Formal Referral
A formal referral to Kaelo Lifestyle International Programme is appropriate when dealing with challenges related to the work performance of an employee. Rest assured that by following the steps below, help is on the way!

1. Consult with the employee regarding the reason for the referral. There should be a consensus between the referring manager and the employee regarding:
a) The impact of the presenting problem on work performance
b) Agreement on the desired outcomes
2. Complete the Kaelo Lifestyle International Formal Referral Consent form. Once completed, the form should be reviewed with the employee and signed.
3. Complete the form below or email the signed and fully completed consent form to lifestyle@www.kaelo.co.za.
4. An Kaelo Lifestyle International Managerial Consultant will establish contact with the referring manager and the employee within 8 working hours of receipt of the referral form to conduct:
a) A managerial assessment with the referring manager, and
b) A clinical assessment with the employee.
5. Kaelo Lifestyle International is committed to providing timely feedback and the referring manager can expect interim feedback subsequent to the initial assessment with the employee and a final feedback report upon completion of the formal referral process.

The Kaelo Lifestyle International formal referral is a tool used by managers to document work challenges related to the performance or conduct of an employee.

In order for the Kaelo Lifestyle International team to facilitate the process, we require as much information as possible, to give us insight into the challenges at hand. Please complete the document in as much detail as possible.

The employee is required to sign the consent form in order for the Kaelo Lifestyle International team to provide the referring manager with progress feedback. Where an employee does not sign the consent form, no feedback will be provided. The formal referral is a voluntary process and employees cannot be forced to sign the consent form.

Fill in the form below or email the completed and signed consent form to lifestyle@www.kaelo.co.za.

Important Information

Company *

Employee's Full Name *

Preferred Time to Contact the Employee

Morning

Afternoon

Referring Manager's Full Name *

Preferred Time to Contact the Referring Manager

Morning

Afternoon

Details of Employee Being Referred

Full Name *

ID No. / Date of Birth *

Position *

Division / Region / Business Unit *

Cell Number *

Work Number *

Email Address *

Next of Kin Name *

Contact Number *

Details of the Referring Manager

Full Name *

ID No. / Date of Birth *

Position *

Division / Region / Business Unit *

Cell Number *

Work Number *

Email Address *

HR Manager (if applicable)

Full Name

Cell Number

Work Number

Email Address

Details of the Referral

What is the reason for this formal referral? *

Please use the list below to indicate the impact of these challenges. If none of the below is applicable, this is probably not a formal referral.

Absenteeism and Attendance

Excessive sick leave

Sick leave trend on Mondays, Fridays, before or after public holidays

Taking leave without permission

Regular need to leave work early

Vague explanation for absence

Frequently away from workstation

Arriving late for work

Taking long lunch breaks

Sleeping on duty

Substance Abuse Problems

Failed random drug or alcohol test

Under the influence at work

Meets criteria for reasonable suspicion

Job Performance Problems

Lower quality of work

Decreased productivity

Increased errors

Missing deadlines

Violence Issues

Threatened / intimidated others at work

Domestic violence

Harassment

Subjected to bullying

Subjected to intimidation/undermining behaviour

Financial Stress

Expressed difficulty managing personal finances

Has requested salary advances or loans

Noticeable signs of financial hardship (e.g. anxiety about pay, discussing debts)

Increased absenteeism possibly linked to financial issues

Garnishment of wages or legal financial notices received

Decline in work focus or emotional well-being linked to financial concerns

OtherOther

Does this referral form part of any disciplinary process? *

Yes

No

Has the issue highlighted in this form been discussed with the employee? *

Yes

No

What are the consequences if the employee's performance does not improve? *

Have the consequences for not improving been discussed with the employee? *

Yes

No

What is the purpose of this referral/desired outcome? (What would you like AskNelson to assist with?) *

How will the employee's improvement be measured (be specific)? *

How long will the employee be given to make the desired changes? *

Consent

I hereby grant consent to being referred to the AskNelson programme. I give consent for my referring manager to receive a report at the end of the intervention regarding my attendance and the progress that was made during the formal referral process. I acknowledge that the personal information I discuss with the counsellor will not be disclosed or detailed in the report and my confidentiality will be protected.

Employee's Signature

Clear

Referring Manager's Signature *

Clear