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The Well Referral Form

Thank you for taking the time to complete this form. Please answer all questions throughly.

Your Name

First Name

Last Name

Phone

(###)

###

####

Name of SOT Staff Member being referred

First Name

Last Name

Please check all positions the person holds:

Paid Employee

Elder

Minister

Deacon

Team Member

Team Manager

Pod Director

Executive Team Member

Reason for Referral

Please describe the event(s) or concerns that have prompted this referral. Please list all facts known and be as detailed as possible.

Area(s) of Concerns

Please review the SOT Staff Handbook that pertains to the referral reason. Please list the specific expectation, policy, or procedure(s) that have been violated:

Desired Outcome

Please list specific criteria, goals, behaviors that are needed for this person to return to serving: