Jason Lavalle, LICSWPsychotherapy · Seattle, Washington
Leave Visit Preparation
Private practice form
Before your appointment

Leave Visit Preparation

Please complete this before your appointment if possible. It helps me understand what has been happening, how work has been affected, and what you are hoping leave will support. Brief answers are fine.

5About 5 minutes
4Short sections
PDFSave when complete
Important: Completing this form does not guarantee that leave, FMLA, disability benefits, or related paperwork will be recommended or approved. Recommendations are based on clinical evaluation and the information available.
Leave Visit Preparation Step 1 of 4
1 · Leave preparation

Where are you in the process?

It is okay if you are not sure about some of this yet.

Have you started the leave or FMLA process with your employer or HR?
Have you received leave paperwork from your employer, HR, or insurer?
Are you currently working with a psychiatrist or other medication prescriber for this concern?
2 · Symptoms and work

What has been affecting work?

Answer based on your recent experience. Select all that apply.

About how long have symptoms been making work more difficult?
Which of the following have affected your work recently?
3 · Work functioning

How difficult has work been?

Rate each area based on the past 2 weeks.

1
Unable 2
Very hard 3
Somewhat difficult 4
No real difficulty
4 · Planning ahead

What would leave help you do?

This helps connect the requested time away from work with a treatment and recovery plan.

If leave is approved, what do you hope that time will help you do? Select all that apply.
If known, what treatment do you expect during leave?
This form helps me prepare for your appointment but does not determine whether leave will be recommended. If another clinician is providing most of the treatment related to your leave request, that clinician may be better positioned to complete some or all of the paperwork.
Jason Lavalle, LICSW · Psychotherapy

Leave Visit Preparation

Patient-completed pre-visit information

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