Accommodation & Leave Requests

Request Mental Health Leave

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Recipient Name

Leave Type

Start Date

Employer Name

Employment Duration

Your Name

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Dear [Recipient Name],

I am writing to formally request medical leave under the Family and Medical Leave Act (FMLA) and/or applicable state leave laws due to a serious health condition.

My treating healthcare provider has advised that I need [Leave Type] beginning [Start Date]. I have been employed at [Employer Name] for [Employment Duration] and understand that I may be eligible for job-protected leave.

I am requesting that HR provide me with the appropriate FMLA paperwork, including the medical certification form (WH-380-E), so that my healthcare provider can complete the required documentation.

Please confirm receipt of this request and provide the FMLA forms at your earliest convenience. I am committed to following all required procedures for requesting leave.

Sincerely,
[Your Name]

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