FMLA Leave Requests

Intermittent FMLA Leave for Mental Health

A fully-written letter you can copy or download. Below the letter we explain why it is written the way it is, the mistakes most people make, and the legal authorities the language invokes.

The letter

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To: HR at [Employer Name]
From: [Your Full Name]
Date: [Today's Date]
Subject: Request for Intermittent FMLA Leave

Dear [HR Contact Name],

I am writing to request intermittent leave under the Family and Medical Leave Act for a serious health condition that is being treated by a licensed provider. I have been with [Employer Name] long enough and worked enough hours to be eligible.

Please send me the WH-380-E medical certification form so my provider can complete it. My provider will fill in the medical detail, including how often and for how long I expect to need leave. Please also confirm in writing that this is being treated as an FMLA request.

I will give as much advance notice as I can for scheduled appointments and notify you as soon as practicable for unforeseen absences.

Thank you,

[Your Full Name]
[Your Work Email]
[Your Phone Number]

Replace every bracketed prompt with your own information before sending. Everything in brackets is for you. Everything outside brackets is the letter.

Before you send this

Many employers do not handle FMLA paperwork themselves. They hand it off to a third-party administrator, usually called a TPA. A TPA is a leave-management vendor, like Sedgwick, Unum, Lincoln, or The Hartford, that your employer pays to process claims. TPAs have an incentive to close claims quickly, and they use a predictable set of tactics to push employees into giving up more than the law actually requires. Watch for these:

Blanket HIPAA authorization forms. These are not required for FMLA. The WH-380-E certification is. A broad HIPAA release can pull therapy notes, substance use records, and unrelated medical history into a corporate vendor's database.
Demands for records beyond the WH-380-E. The law limits what your employer or its TPA can require to what is necessary to determine FMLA eligibility. You are not obligated to provide a full chart.
Artificial delays that trip deadlines. If the TPA says your certification is incomplete, they must tell you in writing exactly what is missing and give you seven calendar days to fix it. Silence is not a legal denial.
Direct calls to your healthcare provider. TPA claim examiners cannot call your provider for general information. Contact for clarification must be routed through a healthcare professional designated by the employer.
Pressure to use an Employee Assistance Program (EAP) instead of accommodations. An EAP is a short-term counseling benefit your employer funds, usually limited to three to eight sessions. An EAP referral is not a response to an ADA accommodation request, and engaging with the EAP can muddy your record.

Watch out for the sign-up process. HR typically sends you to a TPA website to register and "start your claim." Those sign-up flows are where most of the traps live: pre-checked HIPAA authorization boxes, fields asking you to enter your diagnosis, current medications, symptoms, or the contact information for your treating providers. None of that is required to open an FMLA claim. Fill in only the administrative fields (name, employee ID, employer, dates) and leave clinical fields blank.

If the portal will not let you proceed without medical entries, or if anything about the process feels coercive, raise the concern in writing. A short email to HR and the TPA is enough: say that the portal appears to be asking for information that goes beyond what the FMLA certification requires, that you understand the employer's information rights are limited to what is necessary to determine FMLA eligibility, and that you would like to submit your certification through an alternative channel (email or fax to the TPA directly, with your provider sending the completed WH-380-E to that address). Wait for a written response. Only use the alternative if HR or the TPA agrees. Putting the concern in writing either gets you the alternative or creates a paper trail that protects you if the claim is later denied or delayed.

If any of this is happening, read Protecting Your Medical Records, FMLA and HIPAA Privacy Rights, or use the letter that limits records release to a TPA. If you need to talk to someone free of charge, see our list of free legal helplines and crisis lines.

When to use this letter

You are in ongoing treatment for a mental health condition. You need time off for regular appointments and for occasional days when symptoms make work unsafe or unworkable. You are asking HR to open an intermittent FMLA file.

This is a first-time request for intermittent FMLA leave. The letter does two things: it gives HR notice that you have a serious health condition under the FMLA, and it asks HR to send the WH-380-E so your provider can complete it.

Send it by email to your HR contact with a copy to yourself. You do not need to share a diagnosis. Your provider's WH-380-E will supply the medical detail, including how often and for how long you expect to need leave.

Why the letter is written this way

Each paragraph is doing specific legal work.

01
Why ask HR specifically, not your supervisor
Routing the request to HR is what triggers the employer's obligations under 29 C.F.R. § 825.300, including the five-business-day eligibility and rights notice. A supervisor's casual acknowledgment does not start that clock.
02
Why let your provider supply the medical detail
The WH-380-E is where frequency, duration, and clinical specifics belong. Pre-stating estimates in your letter can lock you into numbers that do not match what your doctor or therapist later certifies, and inconsistencies between the letter and the form give HR a reason to delay.
03
Why not name a diagnosis
FMLA does not require disclosure of the diagnostic label as a condition of leave approval. The certification regulation, 29 C.F.R. § 825.306(a), lists 'appropriate medical facts' (which can include symptoms, treatment regimen, hospitalization, and frequency of incapacity) that are required for the cert to be sufficient. The diagnostic label specifically is not. Once a diagnosis is in writing, it cannot be taken back, and it can travel through HR or a third-party administrator in ways you cannot control. Ask your provider to describe the functional limitations and treatment regimen without naming the diagnostic label.
04
Why ask for written confirmation
Asking for written confirmation in the letter triggers the employer's five-day notice obligation under 29 C.F.R. § 825.300(b). A verbal acknowledgment does not.
05
Why mention both kinds of notice
29 C.F.R. § 825.302 requires reasonable advance notice for foreseeable leave. § 825.303 requires notice as soon as practicable for unforeseen leave. Stating you will follow both heads off later attendance disputes.

Don't do this

The mistakes that undo the letter.

01Naming a diagnosis in the written request. You do not have to, and once it is in writing, it cannot be taken back.
02Addressing the letter to your direct supervisor instead of HR. Supervisors do not trigger FMLA notice deadlines the same way; HR does.
03Describing your symptoms in detail. The WH-380-E is for that. Your letter should stay at the 'serious health condition' level.
04Asking for permission ('I was wondering if I could...'). You are not asking. You are notifying your employer of a right you are exercising.
05Pre-stating how often or how long you will need leave before talking to your provider. Let the WH-380-E set those numbers.
06Not keeping a dated copy. Email it to yourself or print and date-stamp it. Memory is not documentation.
07Agreeing verbally to 'just take what you need' without paperwork. Informal arrangements are the fastest way to lose FMLA protection. Donovan v. Nappi Distributors (D. Me. 2023) allowed a lawsuit to proceed specifically because an employer refused to provide paperwork.

Legal authorities cited

The language invokes real regulations.

29 U.S.C. § 2601 et seq.: Family and Medical Leave Act
29 U.S.C. § 2611: FMLA eligibility requirements (12 months, 1,250 hours)
29 C.F.R. § 825.115: Continuing treatment by a healthcare provider
29 C.F.R. § 825.202: Medical necessity for intermittent leave
29 C.F.R. § 825.300(b): Employer's 5-day notice obligation
29 C.F.R. § 825.306(a)(3): Certification does not require a diagnosis
42 U.S.C. § 12112(d)(3)(B): Confidentiality of medical information

Keep reading

Where to go next.

LeaveRights is a free educational tool and does not provide legal advice. No data is collected or stored. Information provided is for general guidance only. Consult a qualified employment attorney for advice specific to your situation.

Each paragraph is doing specific legal work.

Why ask HR specifically, not your supervisor

Why let your provider supply the medical detail

Why not name a diagnosis

Why ask for written confirmation

Why mention both kinds of notice

The mistakes that undo the letter.

The language invokes real regulations.

Where to go next.