Employee First Name

Employee Last Name

Was the employee seen with any of the following?

Select options

Did the person test positive on a drug test?

Yes

Would Not Submit

Ask the employee if they would like help.

Yes

Have drug and alcohol clinician give employee risk assessment to determine whether outpatient support or inpatient treatment would be appropriate

Yes

EAP referral (counseling, food, housing, any other supplemental needs)

NA/ AA/ Celebrate Recovery/ Freedom that Lasts groups and counseling mandated 3 groups a week – Get a signature, time, date, group name, and location from each group

Detox

Inpatient Rehab

A combination of the above

None of above

What type of insurance does the employee have?

Select Options

Please enter treatment cost based on selected insurance:

• If PPO or HMO → Enter actual detox and rehab cost from provider

• If VA or Medicaid → Enter 0 in both fields

• If No Insurance → Enter 2000 for detox (if needed, otherwise 0) and 10000 for rehab

Detox Amount

Rehab Amount

Does this person influence team culture?

Yes

Does the employee play a major role in business operations?

Yes

Does the employee contribute to client retention or revenue?

Yes

Would their departure cause loss of clients or setbacks?

Yes

Would it be difficult to find someone to replace this person quickly?

Yes

Would the employee be willing to attend a faith-based recovery program?

Yes

Enter employee’s current Annual wage:

OC (Onboarding Cost)

Calculate Monthly Wage (M)

Calculate K (Key Employee Factor)

Calculation (OC + M) × K

Calculation D + R + M

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