Behavioral Health Leave Visit Preparation : The Health Clinic

1. Leave Preparation

Your name

Date of birth

Tell us where you are in the leave process. It's okay if you're not sure about some of this yet.

Leave Status

Have you started the leave or FMLA process with your employer or HR?

Yes No Unsure

Have you received leave paperwork from your employer or insurer?

Yes, and I've uploaded it to my patient portal Yes, but I haven't uploaded it yet No Unsure

Requested leave start date (if known)

Requested last day of leave, if known (your clinician will determine approved dates)

Requested leave duration (if known)

Current Care

Have you discussed leave with a treating clinician?

Yes No Not yet

2. Symptoms

Recent Symptoms

About how long have symptoms been making work more difficult?

Which symptoms have you experienced recently? Select all that apply.

Difficulty concentrating Feeling overwhelmed Anxiety or excessive worry Low mood or sadness Low motivation Exhaustion or low energy Difficulty managing emotions Avoiding work responsibilities

Other:

3. Work Abilities

Rate each area based on the past 2 weeks.

	1 Unable	2 Very hard	3 Somewhat difficult	4 No real difficulty
Keeping a steady pace at work Sustained productivity throughout a shift
Staying focused and concentrating Keeping attention on tasks without losing your place
Understanding what's expected of you Grasping daily responsibilities
Handling more than one thing at a time Managing multiple priorities simultaneously
Communicating clearly Getting your point across in writing or conversation
Managing your emotions at work Keeping emotional responses appropriate to the workplace
Following directions and instructions Acting on guidance from supervisors accurately
Getting along with coworkers Working cooperatively without significant friction
Making decisions Reaching conclusions in a reasonable time
Working without close supervision Functioning independently without constant support
Interacting with the public Communicating with customers, clients, patients, or other members of the public

4.Work and Daily Life

Think about the past two weeks, or your most recent two weeks at work. Short answers are enough. Leave optional details blank if you prefer to discuss them at your visit.

What is your job?

Which job tasks are hardest right now?

How many hours are you usually scheduled to work per day?

How many days are you usually scheduled to work per week?

Which best describes your current work situation?

How often do symptoms affect your work?

When symptoms affect you, how much work can you reliably complete?

Does your ability to work change during the day?

In the past two weeks, on how many days did symptoms cause missed work, lateness, an early departure, or use of paid time off?

Have you noticed either of these changes in your work? Select all that apply.

Missed deadlines or unfinished workMore mistakes than usualNone of theseUnsure

Work Feedback and Specific Examples

Think about the period since these difficulties began. Include feedback or events whether or not you believe they are related to your symptoms. You do not need to have received a warning or a poor review to describe difficulty working.

Give one brief example of a work difficulty or feedback you received. What happened and what was the result? If helpful, include who raised it by role and roughly when. Optional; do not include other people’s names.

What feedback or changes have you experienced at work during this period? Select all that apply.

You can discuss these items at your appointment. Do not upload employer, client or coworker confidential information to this form. If records would be useful, your clinician can discuss an appropriate way to provide relevant information.

Can you keep working your current schedule?

What are you doing or experiencing while trying to keep working? Select all that apply.

Working longer or catching up during evenings or weekendsSkipping breaks to keep upRelying on substantial help from coworkersHaving less ability to manage responsibilities outside workSpending most of my time outside work recoveringSleeping less well or needing much more sleepNone of theseUnsure

What have you tried to help you keep working? Select all that apply.

Would a shorter workday or workweek let you do your main tasks?

Is there a change at work that might help? Optional.

Compared with a month ago, are work and daily tasks easier or harder?

5. Care and Leave

Goals for Leave

If leave is approved, what do you hope that time will help you do? (select all that apply)

Attend therapy consistently Start or adjust treatment Improve functioning and daily symptoms Recover enough to return to work Unsure

Other:

Treatment and Your Schedule

Do appointments, treatment or recovery afterward require time away from work?

Before Your Visit

Anything else you want your provider to know before your visit? Optional

Current Care

Answer what you know. You can discuss anything you are unsure about at your appointment.

Who are you currently working with for this concern? (select all that apply)

Health Clinic medical provider Health Clinic behavioral health provider Therapist outside Health Clinic Psychiatrist / prescriber outside Health Clinic Not currently receiving treatment

Are you currently taking medication for this condition?

Which medication(s) do you take? Include doses and recent changes if you know them.

Who are you seeing for treatment?

Treatment dates, if known (optional)

When did treatment for this condition begin with that clinician?

Most recent completed treatment appointment with that clinician

Is your next treatment appointment scheduled?

Next scheduled treatment appointment, if known

If a date is unknown or approximate, explain here. Include dates for other treating clinicians if applicable.

Date completed

Important This form helps your provider prepare for your visit but does not determine whether leave will be recommended. Recommendations are based on clinical evaluation, treatment information, and available documentation. If most of your behavioral health treatment is provided outside The Health Clinic, your outside clinician may be best positioned to complete leave paperwork.

What to do next

1
Save as PDF using the button below.
2
Upload to your patient portal at MyPremiseHealth.com or the My Premise Health app : at least 48 hours before your appointment.
3
Bring your leave paperwork to your appointment if you have it and haven't uploaded it yet.

Questions? Call The Health Clinic: 206-667-3000 | ourcampusclinic.org

Before YourAppointment

Current Care

Before Your
Appointment