sample - successful closure report template slf training

Sample Reports

Successful Closure ReportSLF Training

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

www.banyanconsultants.com

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 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

DATE of

FINAL

SESSION

February 27, 2013 REFERRAL

DATE

February 12, 2013

REPORT

DATE

May 15, 2013 Number of

sessions

until closure

report:

10

Arete Client Code: 12345 Professional ID: abcd

Actual start RTW date: (M/D/YY)

April 27, 2013

Partial or Full RTW at date

of final session (%): 30%

(Expected) date of full

time RTW: (M/D/YY)

July 8, 2013

P a g e | 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


client hopes to find support network at work

3) financial problems


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

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Rationale tool Yes

Writing/Journaling assignment Yes

Anti-depressant skills No

Handouts Managing Anger, Managing

Worry, Relationship building, Relaxation

Skills

Managing worry and relationship building

if Yes, which handout

Other 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

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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

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