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Disability & FMLA Form Request

"*" indicates required fields

1

2

3

Service Agreement*

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

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

Name*

First Middle Last

Date of Birth*

MM slash DD slash YYYY

Today's Date

Month

Day

Year

Email*

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

No

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

Yes

No

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?

If yes, please explain and give examples

	0 - Not Applicable	1 - Never	2 - Sometimes	3 - Always
In the past month have you had trouble cooking?

If yes, please explain and give examples

	0 - Not Applicable	1 - Never	2 - Sometimes	3 - Always
In the past month have you had trouble bathing?

If yes, please explain and give examples

	0 - Not Applicable	1 - Never	2 - Sometimes	3 - Always
In the past month have you had trouble dressing?

If yes, please explain and give examples

	0 - Not Applicable	1 - Never	2 - Sometimes	3 - Always
In the past month have you had trouble with daily grooming and hygiene?

If yes, please explain and give examples

	0 - Not Applicable	1 - Never	2 - Sometimes	3 - Always
In the past month have you had trouble driving?

If yes, please explain and give examples

	0 - Not Applicable	1 - Never	2 - Sometimes	3 - Always
In the past month have you had trouble shopping?

If yes, please explain and give examples

	0 - Not Applicable	1 - Never	2 - Sometimes	3 - Always
In the past month have you had trouble paying bills?

If yes, please explain and give examples

	0 - Not Applicable	1 - Never	2 - Sometimes	3 - Always
In the past month have you had trouble socializing?

If yes, please explain and give examples

	0 - Not Applicable	1 - Never	2 - Sometimes	3 - Always
In the past month, have you had trouble controlling your emotions around others?

If yes, please explain and give examples

Tell us about the difficulties you've had in keeping up relationships lately and who you interact with regularly.

	0 - Not Applicable	1 - Never	2 - Sometimes	3 - Always
In the past month have you had trouble with attention or concentration?

If yes, please explain and give examples

	0 - Not Applicable	1 - Never	2 - Sometimes	3 - Always
On the job: did people notice that your work wasn't up to standards?

If yes, please explain and give examples

	0 - Not Applicable	1 - Never	2 - Sometimes	3 - Always
On the job: were you slow to get things done or unable to meet deadlines?

If yes, please explain and give examples

	0 - Not Applicable	1 - Never	2 - Sometimes	3 - Always
On the job: did you need help from others to get your work done?

If yes, please explain and give examples

	0 - Not Applicable	1 - Never	2 - Sometimes	3 - Always
During your recent employment: Were there days when you just didn't show up for work?

If yes, please explain and give examples

	0 - Not Applicable	1 - Never	2 - Sometimes	3 - Always
During you recent employment: Were you reprimanded, threatened with demotion or removed from responsiblities?

If yes, please explain and give examples

Have your symptoms impaired your work?

Yes

No

Examples

*IMPORTANT* Specific problems, such as poor feedback, errors, job loss, job specific tasks you are unable to perform

What is your plan for returning to work?

(Give approximate dates)

Outside of treatment with us, what are you doing to rebuild your work abilities?

(e.g. studying, practice, volunteer work, activities, vocational rehab)

Are you seeing a therapist outside of the Mood Treatment Center?

Yes

No

Name of Therapist:

City:

Contact Number:

How often are you being seen?

Disability Payment

Please complete the following form to make your payment. Disability Forms - $20 Fee FMLA Forms - $15 Fee*

I'd like to make the payment now

I'd like to make the payment later

Please note that we cannot send out any form(s) until payment is received. If you have any issues or concerns about the fee, please call us at (336) 722-7266.

FMLA & Disability Form Request

Total

Billing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Credit Card

Card Details

Cardholder Name

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