Disability Form

Service Agreement*

By submitting this form, I understand that there is a charge of $20 for disability forms and $15 for FMLA forms 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 Last

Date of Birth*

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?

Your disability claim or ID number:

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

List names of people or companies you'd like to release this information to.*

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

Signature*

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)

If unable to sign, enter your name below to indicate consent to release information.

First Last

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? For which company?

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

When did you stay there (approximately) and what was the name of that hospital or facility?

Which psychiatric condition impairs your work? Mention any medical conditions that contribute to the impairment.

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

CAPTCHA

	0 Not Applicable	1 Never	2	3 Sometimes	4	5 Always
In the past month, have you had trouble doing chores, cooking, cleaning, driving or shopping?
In the past month, have you had trouble socializing or controlling your emotions around others?

	0 Not Applicable	1 Never	2	3 Sometimes	4	5 Always
In the past month, have you had trouble with attention or concentration?
On the job, did people notice that your work wasn't up to standards?
On the job, were you slow or unable to get things done on time?
On the job, did you need help from others to get your work done?
During your recent employment, were there days when you just didn't show up for work?
Were you reprimanded, threatened with demotion or removed from responsibilities during your recent employment?

Disability & FMLA Form Request

Disability Payment