Sample Reports
Successful Closure Report
SLF Training
Closure Report (RTW Successful – Full/Partial) 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 CONTROL # ADDRESS D.O.D. EMPLOYER
Mr John Doe 12345-00678-00 1001 Nowhere St. December 10, 2012 Canada Post
D.O.B. POLICY # PHONE C.O.D. ACM
DIAGNOSIS
depressive episode
OCCUPATION
DATE of FINAL SESSION REPORT DATE
February 27, 2013
REFERRAL DATE
February 12, 2013
May 15, 2013
Number of sessions until closure report:
10
Arete Client Code: 12345
Actual start RTW date: (M/D/YY)
March 2, 1960 12345 987-654-3210 March 10, 2015 Ms Smith phone 123-456-7890 letter carrier
Professional ID: abcd
Partial or Full RTW at date of final session (%): 30%
April 27, 2013
(Expected) date of full time RTW: (M/D/YY) July 8, 2013
388 Roncesvalles Ave, Suite 200 Toronto, ON M6R 2M9 T 866.226.9262 F 416.588.9235 www.banyanconsultants.com
Page |2
Resolved Barriers since Initial/Progress report Barriers mentioned in initial /progress report
Comments/Explanation (if needed)
1) poor daily rhythm
client is able to get up at 7-8 am every day and eat three healthy meals per day and go to bed at 10 pm, client has a regular daily rhythm with work, walks and household chores
2) poor self-care
client gets dressed every day and takes a shower every day
3) poor physical stamina
client is consistent in following the exercise program and has improved physical stamina
4) conflict at work
conflict at work is discussed and solved, client feels confident to continue GRTW
Ongoing Barriers since Initial/Progress report Barriers mentioned in initial /progress report
Comments/Explanation (if needed)
1) sleeping problem still existing barrier
client still has trouble sleeping through the night and would not be able to wake up at 5 am, but this is getting better
2) poor support network still existing barrier
client hopes to find support network at work
3) financial problems still existing barrier
if client will increase working hours his income will rise and solve his financial problems
Which homework tools have you utilized with client?
Stress Inventory
Yes
Worrying assignment
Yes
Time management
No
388 Roncesvalles Ave, Suite 200 Toronto, ON M6R 2M9 T 866.226.9262 F 416.588.9235 www.banyanconsultants.com
Page |3
Rationale tool
Yes
Writing/Journaling assignment
Yes
Anti-depressant skills
No
Handouts Managing Anger, Managing Worry, Relationship building, Relaxation Skills Other
Managing worry and relationship building
if Yes, which handout Please List: thought records
If you have not used home work tools, please provide explanation and suggestions
Which other tools have you used in preparing client for RTW and increasing RTW self efficacy?
Role play Overall Evaluation of Treatment: Client’s Progress in Resolving barriers to RTW: (provide explanation/suggestions for improvement) None Low Moderate Good Very Good 0_________________________________5____________x___________________10 Evaluation/suggestions: conflict is currently also solved, client is still not able to start early in the morning but barriers are expected to resolve over the next few weeks Client’s Level of Engagement in Resolving barriers to RTW: (please provide evaluation) None Low Moderate Good Very Good 0_________________________________5______x_________________________10 Evaluation/suggestions: client has actively participated in online diary and exercise program Client’s progress with self efficacy efforts: (please provide evaluation and suggestions for improvement) None
Low
Moderate
Good
Very Good
0_________________________________5_________x______________________10
388 Roncesvalles Ave, Suite 200 Toronto, ON M6R 2M9 T 866.226.9262 F 416.588.9235 www.banyanconsultants.com
Page |4 Evaluation/suggestions: after successful meeting to solve work conflict client felt more confident in RTW and client experienced at work that he was able to deal with unhelpful thinking Rate the progress in increasing client’s overall functioning thus far: (please provide evaluation) None
Low
Moderate
Good
Very Good
0_________________________________5________________________________10 Evaluation/suggestions: daily rhythm has further improved, sleeping is better, client is more active and able to work 30% Has client worked with the online diary? (Please provide evaluation) Not at all
Sometimes
Daily
0__________________________________5_____________________x_________10 Evaluation/suggestions: none Has client participated in the individual exercise program or increased physical activity otherwise? (Please provide evaluation) Not at all
Sometimes
Daily
0__________________________________5____________________x__________10 Evaluation/suggestions: none Please provide your estimation of risk of relapse. Very low risk
Average risk
High risk
0_____________________________x__5_______________________________10 Evaluation/suggestions to prevent relapse: client needs to continue with the online diary and thought records and continue to search for support network outside of work, GRTW needs to be continued in current pace
Overall Treatment Conclusion and RTW Outcome Summary: Client has improved to the extent that he can continue in the GRTW and RTW full time duties and hours on July 8, 2013
Specific Input for RTW Coordinator or Case Manager :(elements that need to be addressed/considered) Client needs to be followed to make sure that there are no further setbacks
388 Roncesvalles Ave, Suite 200 Toronto, ON M6R 2M9 T 866.226.9262 F 416.588.9235 www.banyanconsultants.com