Mental-health leave templates for BC: the request, the note, and the HR checklist

Read the guide first, then come back for the paperwork

Everything about why is in stress leave in BC: what it actually takes: who can certify a leave and who cannot, what "stress leave" means legally, where the money comes from, and why the return is the part nobody plans. The three companion guides go deeper on the doctor's note, EI sickness benefits and the return to work. This page assumes you have read the first one and gives you the documents.

The facts the templates rest on, each from the government page named in the sources, read on 1 October 2026:

• BC Employment Standards Act, illness or injury leave, After 90 days of employment, five paid and three unpaid days each calendar year. The employer may ask for "reasonably sufficient proof"; the Province's page says a note from a health professional is generally not required unless the absence runs past five consecutive days or is the third health-related leave of the year. Employment is continuous during the leave and the employee returns to the same or a comparable position.
• EI sickness benefits, 55% of average insurable weekly earnings to a maximum of $729 a week in 2026, for up to 26 weeks. The claimant needs 600 insured hours in the 52 weeks before the claim, a drop of more than 40% in weekly earnings, and a medical certificate from an approved practitioner. Service Canada says to apply as soon as possible after stopping work and that waiting more than four weeks can cost benefits.
• The waiting period, One week, for sickness benefits as for the others, since 1 January 2017. Some employers top up; the employee has to ask.
• The Record of Employment, The employer issues it for every interruption of earnings; electronically, within five calendar days after the end of the pay period in which the interruption begins. Illness or injury is reason code D.
• Short- and long-term disability, Set by the plan the employer bought, not by law: its own forms, its own definition of disability, its own deadlines. The sequence is normally sick days, then STD, then EI or LTD. Our page on disability benefits and counselling sets the timelines side by side.

Template 1: the employee's written request for a medical leave

Short on purpose. An employer is entitled to know that you cannot work, from when, and roughly for how long. They are not entitled to a diagnosis, and a letter that offers one cannot be un-sent. Send it by email so there is a dated copy; copy yourself.

• If you are using ESA sick days for a short absence, Replace the first two paragraphs with: "I am unwell and will be taking illness leave under the Employment Standards Act from [date]. I expect to return on [date] and will let you know if that changes." Nothing else is required for a few days.
• If you have no family doctor, Say "a medical certificate will follow once I have seen a physician or nurse practitioner" and give the earliest realistic date. A walk-in clinic or virtual-care visit can certify; the certifying clinician does not have to know you.
• If the employer asks why, A reasonable reply: "The certificate confirms that I am unable to work and when that will be reviewed. My clinician has advised that further medical detail is not required for a leave, and I would like to keep it private."

Email to your manager or HR · select to copy

Subject: Request for medical leave of absence

Dear [manager's name],

I am writing to request a medical leave of absence starting [date].

My health-care provider has advised that I am unable to work at present. The expected review date is [date], and I will update you then or sooner if anything changes. A medical certificate confirming the leave and the expected date will follow [by / attached]. The certificate describes my ability to work rather than the reason for it, which I would prefer to keep private.

So that I can get things in order, could you let me know:

1. Whether the company has a short-term disability plan, and if so, which forms I need and by when.
2. Whether my paid sick days under the Employment Standards Act will be applied first.
3. That a Record of Employment will be issued, as I may apply for EI sickness benefits.
4. Who my single point of contact will be while I am away.

I would prefer to be contacted by email rather than phone during the leave. I will hand over [current work / list] before [date].

Thank you,
[Name]
[Date]

Template 2: what to ask the doctor or nurse practitioner to include

Take this list to the appointment. It is not a note and it contains nothing clinical: it is the shape of what employers, insurers and Service Canada need from the certifying clinician, so that one visit produces one usable document. The clinician decides what to write.

Checklist for the certifying appointment · select to copy

Please ask the certifying physician or nurse practitioner for a note that includes:

[ ] A statement that I am unable to work, and the date that applies from.
[ ] An expected review date, rather than an open-ended leave.
[ ] Function, not diagnosis: what I am unable to do at work during this period, in general terms.
[ ] If a graduated return is likely, a line saying a return-to-work plan will be set at review.
[ ] The clinician's name, designation, registration and contact details, as the insurer or employer will need to verify it.

If I am applying for EI sickness benefits:
[ ] Service Canada's medical certificate for EI sickness benefits, completed and signed, or the clinician's own form with the same information. Ask whether there is a fee; Service Canada does not reimburse it.

If my employer has a short-term disability plan:
[ ] The plan's own attending-physician form, which I will bring, completed by the clinician rather than by me.

Please do not include:
[ ] A diagnosis on the copy that goes to my employer. It is not required for a leave.
[ ] Anything about treatment, medication or what I discuss in counselling.

Template 3: the HR checklist for a mental-health leave in BC

For the manager or HR lead who has just received Template 1. The order matters: the Record of Employment has a legal deadline, the STD plan has a contractual one, and the return is the part that decides whether there is a second leave. Nothing on this list asks for a diagnosis, because nothing on this list needs one.

HR checklist, from receipt of the request to the return · select to copy

ON RECEIPT
[ ] Acknowledge in writing the same day: the leave is approved from [date], subject to the medical certificate; name the single point of contact; confirm the employee's preferred channel (email).
[ ] Do not ask for a diagnosis, symptoms or treatment. Ask only for the certificate: unable to work, from when, review date.
[ ] Check the ESA entitlement: after 90 days of employment, five paid and three unpaid illness or injury days per calendar year. Apply what remains first if the employee asks.
[ ] Confirm the employee's role is held: employment is continuous during leave and they return to the same or a comparable position.

FIRST FIVE CALENDAR DAYS
[ ] Issue the Record of Employment electronically within five calendar days after the end of the pay period in which the interruption of earnings begins. Reason code D, illness or injury.
[ ] If there is a short-term disability plan: send the employee the claim package, the attending-physician form and the plan's deadline, in writing. Note the plan's elimination period and what bridges it.
[ ] If there is no STD plan: tell the employee the route is EI sickness benefits, that they should apply as soon as they stop work, and that the ROE has been or will be filed electronically.
[ ] Confirm whether the company tops up EI, and say so either way.
[ ] Confirm continuation of benefits (extended health, life, pension) during the leave and who pays premiums.

DURING THE LEAVE
[ ] Agree a check-in cadence with the employee, by email, at the review dates on the certificate rather than ad hoc. The check-in is about dates and paperwork, not health.
[ ] Keep all medical documents with HR, not the manager, and separate from the personnel file.
[ ] If the leave outlasts the STD plan, start the LTD claim before STD ends; LTD definitions and waiting periods are the plan's.
[ ] Record every date: request received, certificate received, ROE filed, forms sent, review dates.

BEFORE THE RETURN
[ ] Ask for a fit-to-return note with any functional limitations. Limitations, not diagnosis.
[ ] Build a graduated return-to-work plan in writing: start date, hours per week in each phase, duties in each phase, review dates, who signs off. Four to eight weeks is a common shape.
[ ] Consider the changes the certificate points to (schedule, duties, reporting line). Where a change is requested as an accommodation, document the request and the response.
[ ] Brief the team on the practical facts only: return date and hours. Nothing about the reason.

ON RETURN
[ ] Meet on day one about the plan, not about the leave.
[ ] Hold the review dates. Adjust the plan in writing if the clinician's note changes.
[ ] Note what, if anything, in the work contributed, and what has changed. A return to identical conditions is the usual route to a second leave.

Template 4: a one-page graduated return-to-work plan

The plan the checklist asks for. Written in the open, agreed by the employee and the employer, with the clinician's note as the limit. Return to work after a mental-health leave explains what tends to go wrong without one.

Graduated return-to-work plan · select to copy

Employee: [name]        Role: [title]        Manager: [name]        HR contact: [name]
Return date: [date]     Plan agreed on: [date]     Clinician's note dated: [date]

Functional limitations from the note (if any): [e.g. no on-call duties until review; no more than six hours a day for the first two weeks]

Phase 1  [dates]   [hours per day] on [days]   Duties: [list]   Excluded: [list]
Phase 2  [dates]   [hours per day] on [days]   Duties: [list]   Excluded: [list]
Phase 3  [dates]   [hours per day] on [days]   Duties: [list]   Excluded: [list]
Full duties from: [date]

Review dates: [date], [date]. Who attends: employee, manager, HR.
What happens if a phase is not working: the plan returns to the previous phase and the review is brought forward. This is not a performance matter.
Changes to the work agreed for the return: [schedule / duties / reporting line / other]
Contact during the plan: email, to [name].

Agreed:  [employee]  [date]      [manager]  [date]

What counselling has to do with any of this

A counsellor cannot sign a leave, and no template on this page pretends otherwise. What counselling does is run inside the leave, which is usually what the leave is for, and it is the part that makes the return-to-work plan more than a schedule. Most extended health plans that list a Registered Clinical Counsellor reimburse the sessions, which is plan-dependent and worth checking with the booklet before the first one; does my plan cover counselling has the words to use.

If the leave is for somebody on your team rather than for you, counselling support for BC teams is the employer-facing page.