Disability Form

Disability & FMLA Request Form

This form is required to help us prepare an accurate assessment of your disability. Please answer all questions
honestly, as disability companies will also be looking at your medical records and have ways to identify inconsistencies.

"*" indicates required fields

Service Agreement*

By submitting this form, I understand that there is a charge of $20 for each disability form and $15 for each FMLA form and agree to pay the charge for that service.

Please Note: For Caregiver FMLA, the patient’s name should be listed and the assessment should reflect their point of view.

Name:*

First Middle Last

Date of Birth:*

MM slash DD slash YYYY

Today's Date:

Month

Day

Year

Email Address:*

If Caregiver FMLA - Name of Claimant Seeking FMLA:

What type of disability are you seeking? (If you are fully unable to work, you need to seek short-term before long-term disability)

What type of disability company are you seeking benefits from?

What is your disability claim or ID number

(Look on your forms for the number, OK to leave blank if you can't find it):

Please list names and contact information of people or companies to release this information to*

(include your disability company, lawyer, and others you'd like this information sent to):

In signing below, I give permission for the Mood Treatment Center to release my psychiatric records and disability assessments to the people or companies listed above. I reserve the right to revoke this release at anytime and understand the purpose of this disclosure is for a disability assessment.

(Sign with your mouse: drag your mouse pointer while holding down the left-click button on the mouse to sketch your signature here)

Signature of Patient:*

Date

Month

Day

Year

Signature of Parent/Guardian if Patient is under age of 18:

Date

Month

Day

Year

When did you last work?

When did you first become unable to work?

(If you've been disabled in the past but recovered, just give the date for your current episode of disability).

What was your last job title and employer?

Is this a work-related injury/illness that has caused you to be disabled?

Answering YES usually implies you are seeking a worker's compensation claim.

Yes

Have you ever stayed overnight in a hospital or other treatment facility for mental health?

Yes

If "Yes", please list admission date, discharge date, and name of facility

Which psychiatric condition impairs your work?

Mention any medical conditions that contribute to the impairment.

	0 - Not Applicable	1 - Never	2 - Sometimes	3 - Always
In the past month have you had trouble cleaning and/or doing chores?