Disability/Leave Support Letter (Mental Health)

Date: [date of letter]

To: [recipient name and title if known / To Whom It May Concern]

Re: Leave/Disability Support for [patient full name], DOB [date of birth]

Clinician Role and Authorization

I am the [treating clinician / independent evaluator] for [patient full name]. I have seen the patient from [first contact date] to [most recent contact date] at an approximate frequency of [visit frequency]. This disclosure is provided under the following authorization basis: [patient authorization on file dated (authorization date) / letter provided directly to the patient for submission / no authorization on file]. This letter includes only information relevant to functional impairment and need for leave or related accommodations.

(If "no authorization on file" and the letter is not provided to the patient, state "Unable to release clinical information without authorization" and omit subsequent clinical sections.)

Clinical Summary and Functional Impact

[Diagnosis (DSM/ICD) if required by recipient, or non-diagnostic framing: "a mental health condition causing clinically significant impairment"]. Current clinical status: [concise description of symptom patterns, severity, and stability as related to functional capacity].

Functional limitations materially affecting essential activities: [relevant limitations in observable terms, such as attendance reliability, sustained attention, executive functioning, interpersonal tolerance, or stress tolerance, with basis noted for each (clinical observation / patient report / standardized measures)]. (Avoid psychotherapy content or nonessential sensitive details. If specific essential job/school functions were provided, reference them; otherwise note that functional statements are generalized.)

Leave Recommendation

Recommended leave type: [continuous leave / reduced schedule / intermittent leave / modified duties with temporary accommodations]. Start date: [actual or proposed]. Anticipated end date or duration: [end date or duration range]. Reassessment planned: [reassessment date]. (Use qualifying language such as "anticipated," "estimated," or "subject to reassessment" as clinically appropriate.)

(If intermittent leave, include estimated frequency and duration of episodes/appointments as a range. If modified duties, briefly note recommended accommodations framed as suggestions.)

Treatment Plan and Prognosis

Current treatment: [treatment modalities] at [frequency]. Near-term plan: [brief description of ongoing treatment, adjustments, or monitoring]. Leave/accommodations support recovery by [mechanism, e.g., reducing symptom exacerbation, enabling treatment participation, allowing graded re-engagement].

Prognosis: [favorable / guarded / uncertain] over [timeframe] with treatment adherence. Key uncertainties: [relevant factors]. Monitoring: [markers to guide adjustments]. (If applicable, note that a graduated return may include staged increases in hours/duties as tolerated. Final fitness-for-duty decisions rest with the employer or school.)

Closing

This letter provides my clinical opinion based on information available as of [date of letter]. It documents functional impairment relevant to leave/accommodation but does not constitute a legal disability determination. Conclusions are limited by [constraints, e.g., limited visits, reliance on patient report, lack of detailed job description]. For questions, contact [practice phone/fax]. Release of additional clinical information requires patient authorization.

Sincerely,

[Signature]

[Provider name], [Credentials]
[Specialty/Role]
[Practice name, address, phone, fax]
[License state and number]