Wisconsin Works (W-2) case managers send this report to a participant's mental health professional to understand what work, training and education activities the parent can handle and what accommodations they need. The professional states whether a mental health condition limits participation for up to 40 hours a week, for how long, which job skills the patient can manage and how many hours per week are realistic.
The mental health professional (psychiatrist, psychologist or licensed therapist) completes every section below the agency box and signs by hand. The W-2 agency fills in the patient and return details at the top and includes the patient's signed release.
Download the current version from the source each time; forms change without notice.
Mental Health Report
This form is a Word template, not a PDF. Vero Scribe writes the visit note it draws on, so the details are ready when you complete it.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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Whether a mental health condition limits structured activities up to 40 hours a week and for how long; which of ten work skills the patient can manage, such as coping with work stress; which W-2 activities suit them; needed accommodations; limits in reading, writing, computer use and group settings; expected absences; and weekly hours.
Yes. The directions require a handwritten, wet signature in blue or black ink from the mental health professional. The form can be typed in Word, then printed and signed, and scanned or mailed to the Wisconsin Works agency named at the top.
Yes. The form asks whether, based on the patient's condition, the professional recommends applying for Social Security disability benefits with advocacy from the Wisconsin Works agency. The agency, not the professional, then helps the participant with that application.