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Disability

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Disability

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.
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.
Name*
First Middle Last
Date of Birth*
Month
Day
Year
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?
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 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.
Signature of Patient:
Date
MM slash DD slash YYYY
Signature of Parent/Guardian if Patient is under age of 18:
Date
MM slash DD slash YYYY
When did you last work?
When did you first become unable to work?
(If you've been disabled in the past but recovered, please 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 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
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.
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
Example:
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
Example:
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
Example:
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
Example:
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
Example:
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
Example:
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
Example:
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
Example:
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
Example:
In the past month have you had trouble controlling your emotions around others?
(If yes, please explain and give examples)
- 0 - Not Applicable
- 1 - Never
- 2 - Sometimes
- 3 - Always
Example:
Tell us about the 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?
(If yes, please explain and give examples)
- 0 - Not Applicable
- 1 - Never
- 2 - Sometimes
- 3 - Always
Example:
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
Example:
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
Example:
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
Example:
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
Example:
During your recent employment: Were you reprimanded, threatened with demotion or removed from responsibilities?
(If yes, please explain and give examples)
- 0 - Not Applicable
- 1 - Never
- 2 - Sometimes
- 3 - Always
Example:
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?
Which service are you seeking?
Total
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