Kaelo Lifestyle

Kaelo Lifestyle Formal Referral

Kaelo Lifestyle Formal Referral
The Kaleo Lifestyle formal referral is a tool used by managers where there are documented work challenges related to the performance and or conduct of an employee.
In order for the Kaleo Lifestyle Programme 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 Programme team to provide the referring manager with progress feedback. Where an employee does not sign the consent form, no feedback shall be provided. The formal referral is a voluntary process and employees cannot be forced to sign the consent form.

Your Kaelo Lifestyle Plan *

Important Information

Preferred Time to Contact the Employee
Preferred Time to Contact the Referring Manager

Details of Employee Being Referred

Details of the Referring Manager

HR Manager (if applicable)

Details of the 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
Behavioural Concerns
Job Performance Problems
Substance Abuse Problems
Violence Issues
Does this referral form part of any disciplinary process? *
Has the issue highlighted in this form been discussed with the employee? *
Have the consequences for not improving been discussed with the employee? *


I hereby grant consent to being referred to the Kaelo Lifestyle 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.
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