Mental Health Return to Work Plan
Employee Information
Name
Position/Job Title
Department
Manager/Supervisor
Date of Return
Medical and Support Information
Medical Professional/Support Contact
Contact Details
Work Adjustments & Support
Required Adjustments or Accommodations
Support Needed from Manager or Team
Work Plan & Duties
Proposed Duties Upon Return
Phased/Gradual Return (if applicable)
Flexibility or Adjusted Working Hours
Wellbeing Strategies
Actions for Maintaining Wellbeing at Work
Warning Signs/Triggers to Monitor
Steps to Take if Issues Arise
Review and Check-In
Planned Review Date
Notes
Employee Signature
Date
Manager/Supervisor Signature
Date