Sample Reports

Request for Extension SLF Training

388 Roncesvalles Ave, Suite 200 Toronto, ON M6R 2M9 T 866.226.9262 F 416.588.9235

www.banyanconsultants.com

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 D.O.B. March 2, 1960

CONTROL # 12345-00678-00 POLICY # 12345

ADDRESS 1001 Nowhere St. PHONE 987-654-3210

D.O.D. December 10, 2012 C.O.D. March 10, 2015

EMPLOYER Canada Post ACM Ms Smith

phone 123-456-7890

DIAGNOSIS

depressive episode OCCUPATION letter carrier

INITIAL

SESSION

DATE

February 27, 2013 REFERRAL

DATE

February 12, 2013

REPORT

DATE

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

P a g e | 2

388 Roncesvalles Ave, Suite 200 Toronto, ON M6R 2M9 T 866.226.9262 F 416.588.9235

www.banyanconsultants.com

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

OR

I have read and agree to fund ____ sessions in total

_______________________________________________ ________________

(Printed name) - Abilities Case Manager, Sun Life Financial Date

_______________________________________________

Signature - Abilities Case Manager, Sun Life Financial