Disability Form

Disability & FMLA Form Request

"*" indicates required fields

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*

Today's Date

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

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

Date

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?

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

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

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

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

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

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

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

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

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

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

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

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

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

	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?

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

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