FMLA for Mental Health: Your Comprehensive Guide to Support and Well-being

[Your Name]
[Your Address]
[Your City, State, Zip Code]
[Your Phone Number]
[Your Email Address]
[Employee ID/Personnel Number]

[Date]

[HR Department/Manager Name]
[Company Name]
[Company Address]

Subject: FMLA Leave Request for Serious Mental Health Condition

Dear [HR Department/Manager Name],

I am writing to formally request Family and Medical Leave Act (FMLA) leave due to a serious mental health condition that significantly impacts my ability to perform my job functions. I understand that FMLA provides eligible employees with job-protected leave for qualifying medical reasons.

Type of Leave Requested:

*   [Choose One: Continuous Leave / Intermittent Leave / Reduced Work Schedule]

Reason for Leave:

I am seeking leave for a serious mental health condition, specifically [mention general nature, e.g., severe anxiety, major depressive disorder, PTSD], which requires ongoing treatment and management by a healthcare provider. This condition has made it challenging to [briefly explain impact on work, e.g., concentrate, manage stress, maintain consistent attendance].

Anticipated Leave Period (if Continuous Leave):

*   Start Date: [MM/DD/YYYY]
*   Expected Return Date: [MM/DD/YYYY]

Anticipated Leave Schedule (if Intermittent Leave or Reduced Work Schedule):

I anticipate needing intermittent leave for [e.g., therapy appointments, periods of acute symptom exacerbation]. I expect this to occur approximately [e.g., 1-2 times per week, 2-4 hours per occurrence] for an indefinite period, or until my healthcare provider advises otherwise. I will endeavor to provide as much advance notice as possible for scheduled appointments and will notify my supervisor immediately for unforeseen absences.

Healthcare Provider Information:

I have attached, or will provide separately, the medical certification from my healthcare provider to support this request. My healthcare provider is:

*   Provider Name: [Healthcare Provider's Full Name]
*   Practice Name: [Healthcare Provider's Practice Name]
*   Contact Number: [Healthcare Provider's Phone Number]
*   Email Address: [Healthcare Provider's Email Address]

I understand that I may be required to provide further medical certification and will cooperate fully with any reasonable requests for information. I also understand that I must comply with company policies regarding reporting absences.

Thank you for your consideration of this request. I am committed to my recovery and appreciate your support in this matter.

Sincerely,

[Your Signature]

[Your Typed Name]

---

### Healthcare Provider Certification (To be completed by a licensed healthcare professional)

Patient Name: [Employee's Full Legal Name]
Date of Birth: [Employee's Date of Birth]

Healthcare Provider Information:

*   Provider Name: [Healthcare Provider's Full Name]
*   Practice Name: [Healthcare Provider's Practice Name]
*   Specialty: [e.g., Psychiatrist, Psychologist, LCSW]
*   License Number: [Healthcare Provider's License Number]
*   Contact Number: [Healthcare Provider's Phone Number]
*   Email Address: [Healthcare Provider's Email Address]
*   Date of Examination/Treatment: [MM/DD/YYYY]

Medical Necessity for Leave:

I certify that the above-named patient has a serious mental health condition that qualifies under the Family and Medical Leave Act (FMLA). The patient's condition is [briefly describe the condition and its severity, e.g., Major Depressive Disorder, severe anxiety disorder, Post-Traumatic Stress Disorder].

This condition requires [e.g., ongoing therapy, medication management, periodic hospitalization, reduced exposure to stressors] and renders the patient unable to perform the functions of their position, or requires them to take intermittent leave for treatment or periods of incapacity.

Impact on Work:

The patient's condition impacts their ability to perform the essential functions of their job, specifically [e.g., concentration, decision-making, stress management, consistent attendance, interaction with colleagues].

Treatment Plan:

The patient is currently undergoing a treatment plan that includes [e.g., psychotherapy, pharmacotherapy, group therapy, cognitive behavioral therapy].

Prognosis/Duration of Condition:

*   Expected Duration of Condition: [e.g., Indefinite, 6 months, 1 year]
*   Expected Duration of Incapacity (if continuous): [MM/DD/YYYY] to [MM/DD/YYYY]

Intermittent Leave/Reduced Schedule (if applicable):

I certify that the patient will require intermittent leave or a reduced work schedule due to their condition. The medical necessity for intermittent leave is [explain why intermittent leave is needed, e.g., to attend regular therapy sessions, manage acute symptom flare-ups, recover from treatment].

*   Estimated Frequency of Absences: [e.g., 1-2 times per week, 2-4 times per month]
*   Estimated Duration of Each Absence: [e.g., 2-4 hours, full day]

Healthcare Provider's Signature:

[Healthcare Provider's Signature]

[Healthcare Provider's Typed Name]

[Date]

graph TD
    A[Employee Requests FMLA] --> B{Mental Health Condition?}
    B -- Yes --> C[Healthcare Provider Assessment]
    C --> D[AI Medical Scribe & Clinical Documentation]
    D --> E[Generate FMLA Certification]
    E --> F[Employee Submits FMLA Request & Certification]
    F --> G{Employer Reviews Request}
    G -- Approved --> H[FMLA Leave Granted]
    H --> I[Patient Receives Treatment]
    I --> J[Prior Authorization & Insurance Verification]
    J --> K[HealOS Patient Data Management]
    K --> I
    G -- Denied --> L[Appeal Process]