Medical Leave Documentation Policy

This policy outlines the criteria and procedures under which this practice will complete documentation to support a client’s request for medical leave from employment, including but not limited to the Family and Medical Leave Act (FMLA), short-term disability (STD), long-term disability (LTD), and other employer or state-sponsored leave programs.

Therapeutic Relationship Requirement

To ensure ethical and clinically sound support, the client must have an established therapeutic relationship with this practice prior to any documentation being completed. This means:

A comprehensive initial intake evaluation has been completed.
The client has participated in at least three therapy sessions within the past 30 days following intake.
The therapist has had sufficient opportunity to assess the client's condition, functional limitations, and response to treatment.

Note: The intake appointment does not count toward the three-session minimum.

Types of Documentation Supported

Upon meeting the criteria above, this practice may provide documentation for the following types of leave:

FMLA (Family and Medical Leave Act)
Short-Term Disability (STD)
Long-Term Disability (LTD)
State Paid or Unpaid Medical Leave
Job Accommodation Requests under the Americans with Disabilities Act (ADA)
Employer-Specific Personal or Mental Health Leave Policies

The therapist’s role is limited to providing a clinical summary that verifies treatment, outlines relevant diagnoses, and describes functional limitations when clinically appropriate. Final decisions about leave or accommodations rest with the employer, insurer, or state agency.

Therapist Discretion & Ethical Limitations

The therapist reserves the right to decline requests for documentation if any of the following apply:

The client has not met the minimum treatment criteria.
There is insufficient clinical evidence to support a diagnosis of functional impairment.
The therapist cannot ethically justify the need for leave.
The request is made during the first session or without adequate therapeutic engagement.

Documentation will not be backdated without contemporaneous clinical records that justify it.

Documentation Process and Timelines

All requests for documentation must be made in writing.
Please allow 10 business days for review and completion of forms.
A follow-up session may be required to assess readiness for leave or to complete specific paperwork.
A documentation fee may apply for administrative time spent completing non-clinical forms (e.g., FMLA, disability forms). Clients will be informed of any fees in advance.

Client Acknowledgment

Clients will be required to sign a form acknowledging the following:

They have read and understand this policy.
Documentation will only be provided at the therapist’s discretion, based on clinical findings.
There is no guarantee of leave approval by any third party (employer, insurer, government).
False or misleading requests may result in termination of services.