Due to the debilitating nature of some mental health-related symptoms, it is not uncommon for clients to request documentation for leave of absence requests, including short-term/long-term disability (STD/LTD) and Family and Medical Leave Act (FMLA) certification. Given this, it is important to be familiar with the evolving legislative landscape that impacts these requests. This article will outline best practices and scope of practice considerations to guide a therapist’s involvement in creating documentation for leave of absence requests from clients.
Scope of Practice: Key Considerations
If a client is considering a leave of absence related to their mental health, it is likely an extremely challenging time in their life. They are now faced with the daunting prospect of filing for disability, which will require both advocating for themselves and your support. Your very first step is to discuss your client’s needs with them, and be clear about how your scope of practice informs how you can best assist them. In many states (including but not limited to California, Texas, Florida, and New York), mental health therapists’ documentation is not sufficient for a client to be approved for STD/LTD or FMLA.
In order to ensure a positive and streamlined client experience, Rula strongly recommends the client be referred to a provider whose licensure allows them to complete documentation for disability/FMLA purposes, such as MDs/DOs and NPs. This covers best practice in most states; however, there are some state-specific nuances, so we recommend to consult with your state licensure board for the most updated information.
To begin, ask the client if they are a Kaiser member. This will determine their next steps:
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Non-Kaiser member can be referred to a Rula medication management provider for a mental health evaluation using this form.
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Kaiser members should be referred back to Kaiser for an internal Kaiser evaluation using this form.
- Clients that have an established psychiatric medication management provider outside of Rula should contact their established provider for further evaluation.
Please inform the client that they are being seen for a mental health medication evaluation and to establish care with a mental health medication provider. A relationship with the provider is required before any determination of disability can be made. It often takes multiple visits before enough information is gathered to make an appropriate determination regarding disability status and form completion is NOT guaranteed.
Therapists are able to contribute to the leave of absence process by providing a treatment summary to the client. Clients should be advised that this is NOT sufficient on its own, but CAN be used as a tool to advocate for their leave of absence request.
Your role in this process is to provide accurate, concise, and legally compliant documentation based on your professional expertise that discloses the minimum information necessary in order to protect your client’s privacy. Before drafting documentation, secure written consent from the client to release information.
Elements of an Effective Treatment Summary
Overview of Treatment:
- Start and end dates of treatment.
- Summary of primary concerns or diagnosis.
- Symptoms and their severity.
- How the client’s mental health condition/symptoms affects their quality of life and ability to function effectively
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Treatment Goals:
- Specific goals established collaboratively with the client.
- Goal status: is the treatment goal(s) still in progress, or have been achieved?
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Progress and Outcomes:
- Observable improvements or milestones reached.
- Changes in symptoms or client-reported progress.
- Barriers or challenges encountered during treatment.
- Plans for follow-up or ongoing support.
- If applicable, reason for ending treatment (e.g., goal achievement, client decision).
Knowing how to best support clients with leave of absence requests is a critical component of client care at Rula. By understanding your scope of practice, adhering to state-specific requirements, and following best practices, you can effectively assist clients to navigate the process of applying for disability and/or medical leave.