Sample Reports
Request for Extension SLF Training
Request for Session Extension From:
(Add your name and title) Arete Human Resources Suite 210, 8180 Macleod Trail S Calgary, AB, T1H 2B8 Telephone: 1-888-255-5196 ext Fax: 1-403-252-6161
AUTOPOPULATED CLAIMANT Mr John Doe CONTROL # 12345-00678-00 ADDRESS 1001 Nowhere St. D.O.D. December 10, 2012 EMPLOYER Canada Post
D.O.B. POLICY # PHONE C.O.D. ACM
DIAGNOSIS
depressive episode
OCCUPATION
INITIAL SESSION DATE REPORT DATE
February 27, 2013
REFERRAL DATE
March 2, 1960 12345 987-654-3210 March 10, 2015 Ms Smith phone 123-456-7890 letter carrier February 12, 2013
April 19, 2013
Arete Client Code: 1234
Professional ID: abcd
Date of last Session prior to this request(M/D/YY): April 18, 2013
Number of sessions prior to this request: 7
Specify Number of Additional Sessions Being Requested: 2
costs: (filled out by Banyan)
If client has not returned to work please provide explanation why client has not returned to work Client was supposed to start GRTW April 20 but had a serious setback after addressing conflict at work, and currently also has a flu, advice is to postpone GRTW to April 27 Please provide rationale for extension of sessions and explanation of treatment focus to achieve RTW outcome Client will need a few sessions while in the GRTW to address upcoming issues and restore unhelpful thinking Please provide detailed expectations with regards to RTW & impact of additional sessions on Return to Work Outcome It is still expected that client will start GRTW but additional sessions are needed to ensure success with RTW
388 Roncesvalles Ave, Suite 200 Toronto, ON M6R 2M9 T 866.226.9262 F 416.588.9235 www.banyanconsultants.com
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Current Treatment Conclusion and RTW Outcome Summary/Comments: Client has improved with regards to all barriers but needs to further improve mental stamina to be able to deal with other people at work and setbacks
Updated Input for RTW Coordinator or Case Manager (elements that need to be addressed/ considered):
allow 2 extra sessions and 1 week postponing GRTW to ensure successful GRTW
AUTHORIZATION OF EXTENDED SESSIONS:
I have read and agree to fund the session extensions as requested
I have read and agree to fund ____ sessions in total
OR
_______________________________________________ (Printed name) - Abilities Case Manager, Sun Life Financial
________________ Date
_______________________________________________ Signature - Abilities Case Manager, Sun Life Financial
388 Roncesvalles Ave, Suite 200 Toronto, ON M6R 2M9 T 866.226.9262 F 416.588.9235 www.banyanconsultants.com