Request for Form / Letter Completion
Patient Name
*
First Name
Last Name
Date of Birth
*
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Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Clinician Name:
*
Date form / letter requested:
*
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Month
-
Day
Year
Date
Date form / letter needed: (if less than two weeks from date of request, please ask for extension from your work or school, or schedule appointment with your clinician to discuss)
*
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Month
-
Day
Year
Date
What is desired outcome of form or letter?
*
If FMLA form: Please make sure employee section is filled and signed
*
Yes
No
Do you need one set period of time off work due to mental health condition?
*
Yes
No
Dates of incapacity:
Do you need episodic periods of missing work due to mental health condition?
*
Yes
No
How many episodes per month? (e.g. 0 – 4 episodes / month)
*
How many hours or days per episode? (range okay, i.e. 2 hours – 2days / episode)
*
To whom do we send the form / letter? Please include all necessary information.
*
Submit
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