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Employee Counseling Form

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The Employee Counseling Form acts as a reliable method to verify a counseling session has been provided to an Employee by an appropriate professional (i.e. behavioral trainer, psychologist, etc.). Generally, such documentation is used to provide a paper trail for Human Resources, and sometimes, Insurance Companies, to follow. Thus, having a standard form that may be quickly filled out, at the time of the Counseling Session, will be beneficial to any interested party. Additionally, this form will provide a structure so that some basic summary information regarding the Counseling Session may be reported and reviewed in an efficient manner.

How To Write

Step 1 – Download the “Employee Counseling Form,” from the PDF, ODT, or Word buttons listed on the right side of this page.

Step 2 – In the upper right hand corner of this page, report the Date this document is being completed. Then, report the Full Name of the Employee being evaluated on the blank space labeled “Employee’s Full Name” and report the official Position this Employee holds on the blank line labeled “Job Title.”

Step 3 – Locate the blank labeled “Worksite Employer,” you must report the Full Name of the Employee’s Supervisor, Department, or Company that employs this individual. Then, on the blank line labeled “location,” report the location where this Employee works. This may be an internal designation for a specific office or a general location such as the city and state so long as the entity accepting this form considers it a legitimate identification of the location being defined.

Step 4 – Locate the statement beginning with the words “This Counseling…” This section will provide several choices: Attendance, Behavior/Teamwork, Inappropriate Conduct, Inappropriate Dress, Safety Violation, Sleeping on the Job, Substandard Work, Violence, or Other. You may only select one of these check boxes. If the reason is not mentioned you may mark the check box labeled “Other,” then define the reason on the blank space provided.

Step 5 – Report the Date of the Incident that has caused this evaluation to be called for on the blank line labeled “Incident Date.” Then, report the Time this occurred on the blank line labeled “Time of Incident.”

Step 6 – If a specific incident has caused this evaluation to be called for, give as many details regarding it as possible on the blank lines below the words “Describe the nature of the incident (if applicable).”

Step 7 – If there were any Witness(es) to an incident or incidents causing this evaluation then report their Identities (and if possible, Contact Information) on the line below the words “Name of Witness(es).”

Step 8 – If you have suggestions for any action available to the Employer that may resolve the behavior or incident at the focus of this evaluation, you may report this in on the lines beneath the words “Corrective Action.”

Step 9 – If the Employee being evaluated has any comments regarding what is being defined here, this may be reported on the blank lines labeled “Employee Comments.”

Step 10 – Several Signatures will need to be provided to validate this report. The Employee in question should Sign his or her Name on the line labeled “Employee’s Signature,” print his or her Name on the blank line labeled “Print Name,” and enter the Signature Date on the blank line labeled “Date.”

Step 11 – The Employee’s Supervisor must also Sign and Print his or her Name and provide a Signature Date on the line beginning with the space labeled “Supervisor’s Signature.”

Step 12 – Finally, the Witness at hand must Sign and Print his or her Name on the lines labeled “Witness(es) Signature” and “Print Name” (respectively) then, enter the Date he or she Signed this document on the blank line labeled “Date.”

Step 13 – This form should be submitted to the Employee and his or her Supervisor unless otherwise indicated by Company Policy.



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