Free Mental Health Doctors Note

Patient Name:
Date of Birth: / /
Date of Visit: / /
To Whom It May Concern,
This is to confirm that [Patient Name] was evaluated by me on [Date of Visit] for mental health concerns. Based on my professional assessment, the patient is experiencing and requires to support their well-being.
It is recommended that the patient be excused from work/school from / / to / / , if applicable. Additional accommodations, if needed, may include:
Please feel free to contact my office for any further information.
Provider’s Name:
Clinic/Facility Name:
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