Disability

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.

Service Agreement*

By submitting this form, I understand that there is a charge of $20 for disability forms and $10 for FMLA forms and agree to pay the charge for that service.

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:

Please look on your forms for the number, or leave this field blank if you cannot find it

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

Include your disability company, lawyer, and others you'd like this information to be sent to)

In signing below, I give permission for 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 any time and understand the purpose of this disclosure is for a disability assessment.

When did you last work?

When did you first become unable to work? (If you have been disabled in the past but recovered, please 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 that you are seeking a workers compensation claim.

Yes
No

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

Yes
No

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.

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?

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

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, threated with demotion, or removed from responsibilities during your recent employment?

How have your symptoms impaired your work? (Mention specific problems, such as poor feedback, errors, job loss).

What is your plan for returning to work?

Give approximate dates if possible. Outside of treatment with us, what are you doing to rebuild your work abilities? (e.g. Studying, practice, volunteer work, activities, vocational rehab).

Which service are you seeking?

Total

$0.00

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