Free form template · Word

Counselling Assistance Request

A counselling assistance request form is used where the company provides an in-house or empanelled counsellor rather than a full EAP. The employee requests sessions, chooses mode and urgency, and can ask for paid time off for sessions without disclosing personal details to their manager.

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[Company Logo][Company Name]

COUNSELLING ASSISTANCE REQUEST

Company:: [Company Name]
Request Date:: [Date]
Confidential Contact:: [HR Name]

This form is seen only by [HR Name] for scheduling. It is not placed in your personnel file. If you need urgent help now, call [Helpline Number].

Your Details

Employee Name
Employee ID
Work Location
Mobile Number
Preferred Language

Session Preference

Counsellor: In-house [Counsellor Name] / Empanelled Partner [Partner Name] / No preference
Mode: In person / Phone / Video
Urgency: Today / This week / Flexible
Preferred Days and Times

Area You Would Like Help With (optional)

Stress or anxiety
Work-related concerns
Personal or family matters
Bereavement
Prefer to discuss with counsellor

Session Leave

I request [Number] hours of paid time off for each session under leave code [Code]
Dates requested

Reimbursement (external sessions only)

Session Date	Professional	Receipt No.	Amount (₹)
[DD/MM/YYYY]	[Name]	[Receipt No.]	[Amount]
[DD/MM/YYYY]	[Name]	[Receipt No.]	[Amount]
	Total		[Amount]

Consent

I request counselling support and agree that [HR Name] may share my name and contact details with the counsellor only for scheduling. I understand that session content is confidential to the counsellor.

Employee
[Employee Name]
Date: [Date]

Scheduled by
[HR Name]
First Session: [DD/MM/YYYY]

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What this template includes

Choice of counsellor or empanelled partner
Urgency level with a same-day option
Mode: in person, phone or video
Session leave request worded without details
Reimbursement section for approved external sessions
Privacy assurance and record-keeping rule

When to use it

Companies with a visiting or in-house counsellor at the office or plant
When an employee needs session time during working hours
After a workplace incident, accident or loss of a colleague
When HR arranges reimbursement for sessions with an empanelled professional

How to customise this template

1Add your counsellor's schedule and room or link
2Set the number of company-paid sessions
3Decide the leave code used for sessions in your attendance system
4Specify who receives the form, ideally a designated HR person only

HR tips

Limit access to the request to one trained HR contact
Use a neutral leave code so the reason is not visible to the team
Provide a crisis helpline on the form itself
Do not ask for diagnosis or history; the counsellor will assess

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Frequently asked questions

Can I get leave for a counselling session?+

Many companies allow short paid leave or flexible time for counselling. This form lets you request it without stating the reason to your manager.

Are counselling sessions at work confidential?+

Yes, professional counsellors maintain confidentiality, except where there is a serious risk to safety. HR only coordinates scheduling.

How many counselling sessions does the company pay for?+

It depends on company policy; the form states the number of sessions covered.

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[Company Name]
Request No.:
[Reference Number]
Date:
[Date]
Priority:
Urgent (in hospital) / Normal
Employee and Policy
Employee Name
Employee ID
Department
Mobile Number
Policy Type: Group Health / Group Personal Accident / Group Term Life
Patient / Insured Member Name
TPA / Insurer Claim Number
Nature of Assistance Needed
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- Claim partly settled / deductions unclear
- Document query from TPA
- Other: [Details]
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Course Name
Institution / Certifying Body
Mode: Part-time / Online / Weekend / Full-time
Start Date
Duration
Exam / Semester Schedule

[Company Logo][Company Name]

REQUEST FOR ADDITION OF MEMBERS

Ref. No.:: [Reference Number]
Date:: [Date]

To,
[Insurer / Broker Name]
[Address]

Subject: Addition of members under Policy No. [Policy Number] – [Company Name]

Dear Sir/Madam,

Please add the following members to our group policy(ies) with effect from the dates mentioned below. Kindly adjust the applicable premium against our CD Account No. [Account Number] and share the endorsement copy and e-cards at the earliest.

Emp ID	Member Name	Relationship	Date of Birth	Gender	Effective Date	Policies (GMC/GTL/GPA)	Sum Insured (₹)
[Employee ID]	[Employee Name]	Self	[DD/MM/YYYY]	[M/F]	[Date of Joining]	[GMC, GTL, GPA]	[Amount]
[Employee ID]	[Member Name]	Spouse	[DD/MM/YYYY]	[M/F]	[DD/MM/YYYY]	[GMC]	[Amount]
[Employee ID]	[Member Name]	Child	[DD/MM/YYYY]	[M/F]	[DD/MM/YYYY]	[GMC]	[Amount]
[Employee ID]	[Employee Name]	Self	[DD/MM/YYYY]	[M/F]	[Date of Joining]	[GMC, GTL]	[Amount]

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[Company Logo][Company Name]

REQUEST FOR DELETION OF MEMBERS

Ref. No.:: [Reference Number]
Date:: [Date]

To,
[Insurer / Broker Name]
[Address]

Subject: Deletion of members from Policy No. [Policy Number] – [Company Name]

Dear Sir/Madam,

We request you to delete the following members from our group policy(ies) with effect from the dates stated. Kindly deactivate their e-cards and credit any refundable premium to our CD Account No. [Account Number].

Emp ID	Member Name	Relationship	Deletion Date	Reason	Claim Pending (Y/N)
[Employee ID]	[Employee Name]	Self + Family	[Last Working Day]	Resignation	[Y/N]
[Employee ID]	[Employee Name]	Self	[Last Working Day]	Termination / Retirement	[Y/N]
[Employee ID]	[Member Name]	Child	[DD/MM/YYYY]	Age limit crossed	[Y/N]
[Employee ID]	[Member Name]	Spouse	[DD/MM/YYYY]	No longer eligible	[Y/N]

Where a claim is marked as pending, please continue processing it for treatment taken during the period of cover. Employee [Employee Name] has requested information on portability or conversion; kindly contact them at [Mobile / Email].

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[Company Logo][Company Name]
EMPLOYEE ASSISTANCE PROGRAMME (EAP) REQUEST FORM
Company:
[Company Name]
EAP Provider:
[Provider Name]
24x7 Helpline:
[Phone Number]
Date:
[Date]
Confidentiality: Your request goes to [Provider Name]. The company receives only anonymous, aggregated usage data. Information is shared only with your consent or where there is a serious risk to safety. If you are in immediate danger, call [Emergency Number] or go to the nearest hospital.
Who Needs Support
Name of Person Seeking Support
Relationship to Employee: Self / Spouse / Child / Parent
Employee ID (for eligibility check only)
City
Type of Support
- Emotional wellbeing and counselling
- Work stress or relationship at work
- Family or relationship concerns
- Legal information and guidance
- Financial and debt guidance
- Childcare or eldercare information
- Grief or critical incident support
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Name of Person Seeking Support
Relationship to Employee: Self / Spouse / Child / Parent
Employee ID (for eligibility check only)
City

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COMPANY TRANSPORT / CAB REQUEST

Company:: [Company Name]
Request No.:: [Reference Number]
Date of Request:: [Date]

Requester

Employee Name
Employee ID
Department
Mobile Number
Cost Centre / Project Code

Trip Details

Trip Type: Late-night Drop / Client Visit / Airport-Station Transfer / Site Visit / Holiday Working / Other
Business Reason
Date of Travel
Pickup Time
Pickup Location
Drop Location
One-way / Return
Number of Passengers
Vehicle Type: Hatchback / Sedan / SUV / Tempo Traveller

Passenger List (if more than one)

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MEAL CARD SERVICE REQUEST
Company:
[Company Name]
Vendor:
[Vendor Name]
Request No.:
[Reference Number]
Date:
[Date]
Employee Details
Employee Name (as on card)
Employee ID
Department
Registered Mobile Number
Email ID
Request Type
- New card (enrolled but not received)
- Replacement: lost / stolen / damaged
- Block card
- Unblock card
- Switch from physical to digital
- Update registered mobile number
Card Details
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[Company Logo][Company Name]
EMPLOYEE WELFARE ASSISTANCE REQUEST
Company:
[Company Name]
Request No.:
[Reference Number]
Date:
[Date]
Handling:
Confidential
Applicant
Employee Name (or family member applying on behalf)
Employee ID
Department
Years of Service
Mobile Number
Nature of Hardship
- Medical emergency (self or dependant)
- Death in the family
- Natural calamity / fire / accident to property
- Other serious hardship: [Details]
Details of Need
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Employee Name
Employee ID
Designation
Department
Date of Joining
Reporting Manager
Last Performance Rating

Employee Name (as on card)
Employee ID
Department
Registered Mobile Number
Email ID

Employee Name (or family member applying on behalf)
Employee ID
Department
Years of Service
Mobile Number

Counselling Assistance Request

Preview of the form

Your Details

Session Preference

Area You Would Like Help With (optional)

Session Leave

Reimbursement (external sessions only)

Consent

What this template includes

When to use it

How to customise this template

HR tips

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Frequently asked questions

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