Department of Public Welfare PSYCHOLOGICAL IMPAIRMENT REPORT

Size: px

Start display at page:

Download "Department of Public Welfare PSYCHOLOGICAL IMPAIRMENT REPORT"

Annabella McGee
6 years ago
Views:

1 Department of Public Welfare PSYCHOLOGICAL IMPAIRMENT REPORT The purpose of this report is to outline the information needed to make a disability determination. This is not a required format; however, the information requested herein must be provided to the Department of Public Welfare in order to complete the Federal Social Security Disability application process. Upon request of this information, a provider has 10 business days to respond with the information. If you have any questions, please contact the DAP supervisor at your local County Assistance Office. Consumer First Name: Consumer Last Name: Consumer ID Number: Consumer Date of Birth: Date Report completed: Clinician Name: Clinician Position/Title: Clinician Agency: Clinician Contact Info.: Clinician Signature: 1. What is the current diagnosis of the patient/ consumer? Axis I Axis II Axis III Axis IV Axis V Onset Date Date Treatment Began Date of Most Recent Evaluation Last Date of Service 2. Please attach all evaluations and testing that has been completed. For reports that you have attached, list the name of report and date completed below. For reports that you have from others, but cannot release, please list the name of report, the clinician completing it and any contact information available. (Attach additional sheets if necessary.) A. Completed by yourself/your agency: Name of report Date Clinician s Name Contact Information Psychological Impairment Report Page 1 of 7

2 B. Not completed by yourself/ your agency, but are available: Name of report Date Clinician s Name Contact Information 3. Please CHECK as many of the recurring clinical manifestations/symptoms as applicable. Also indicate whether the symptom is occurring currently or in the past. If current, please indicate severity mild, moderate, or severe using the following abbreviations: C= Current; P= Past; M= Mild; MO = Moderate; and S= Severe A. Organic Mental Disorders (Brain Dysfunctions) Time/place/person disorientation Memory impairment short term, long term, remote Perceptual or thinking disturbances Mood disturbances or mood swings Emotional disturbance Loss of measured intelligence of at least 15 IQ points Impulse control impairment Emotional lability B. Psychotic Disorders (schizophrenia, paranoia, etc.) Delusions Hallucinations Grossly disorganized behavior Catatonia Blunt affect Flat affect Incoherence Loosening of associations Illogical thinking Emotional withdrawal Emotional isolation C. Affective disorders (mood disturbances) Depression C P M MO S Mania C P M MO S Anhedonia Hyperactivity Weight loss Pressures of speech Sleep loss Flight of ideas Psychomotor agitation Inflated self esteem Psychomotor retardation Decreased need for sleep Decreased energy Easy distractibility Feelings of guilt Suicidal thoughts Feelings of worthlessness Hallucinations Acting without regard to likely painful Delusions consequences Suicidal thoughts Paranoid thinking Difficulty concentrating or thinking Psychological Impairment Report Page 2 of 7

3 D. Anxiety Related disorders Motor tension Automatic hyperactivity Apprehensive expectation Vigilance and scanning Agoraphobia Irrational fears and avoidance of an object, activity, or situation Severe panic attacks. Specify frequency. Recurrent obsessions of compulsions Recurrent intrusive recall of traumas Recent trauma, such as death/ loss of a significant other. Please explain. E. Somatoform disorders Persistent disturbance of the following with little or no physiologic basis for the symptom (select one): Vision Speech Other (e.g. psychogenic seizures) Hearing Use of limb OR Exaggerated symptoms due to psychological stressors C P M MO S OR Pain and preoccupation with a disease C P M MO S F. Personality disorders Seclusiveness Autistic thinking Pathological aggressiveness Oddities of thought, perception, speech and behavior Pathological suspicion and/ or transient paranoid ideation Unstable interpersonal relationship with damaging behavior Pathological dependence Pathological passivity Pathological hostility Inability to articulate thoughts and feelings Suicidal/ homicidal or unable to care for oneself C P M MO S G. Mental Retardation and Autism Disorders Dependence on others for personal needs Inability to function without significant help of others or supervision of everyday activities and decision-making Deficit in social and communicative skills Verbal, Performance, and/or Full Scale IQ 60 69, inclusive C P M MO S Psychological Impairment Report Page 3 of 7

4 4. Are there certain situations which cause or trigger the symptoms noted in Question 3? If so, please describe them briefly on a separate sheet or narrative report, including the severity of the symptoms, including intensity and frequency. Consider: Encounter with other people Encounter with groups of people Parties or other social functions Work setting At personal residence with family or other living arrangement At school Travel Idiosyncratic Stressors Other Please identify 5. Provide the name, location and dates of any psychiatric hospitalizations and/or Emergency room visits. 6. Does this illness cause an inability to work, attend school, and provide for complete personal hygiene or other daily activities of living? 7. Does this illness impair the ability to maintain social relationships or social functioning? Yes No If yes, please describe: 8. Has this illness caused deficiencies of concentration, motivation or persistence resulting in frequent failure to complete required daily tasks of living? Yes No If yes, please describe (include work setting examples): 9. Has this consumer been able to work successfully in the past and now cannot due to deterioration in social relationships or work performance? Yes No If yes, please describe and state frequency: 10. Is this consumer s living situation a highly structured and supportive setting? Yes No Psychological Impairment Report Page 4 of 7

5 If no, does the consumer need such a setting? Yes No If yes, please describe why 11. Is this consumer s illness under sufficient control such that he/ she is able to work in a nonsheltered competitive work setting? 12. Was this consumer previously able to work in either a sheltered or non-sheltered work setting, but now cannot? 13. Only answer #13 if the consumer is psychotic. When psychotic symptoms are well-controlled, is the patient able to work? 14. How is this consumer treated for the Axis I and II illnesses listed in Question 1? Please indicate frequency and type of therapy provided. 15. Please list the name, dosage and frequency of medication. 16. What, if any, functional restrictions are caused by prescribed medication, such as metabolic syndrome and or cognitive impairment? Please describe. 17. What has been the consumer s response to treatment with regard to motivation and collaboration with the process, and what is your prognosis? Psychological Impairment Report Page 5 of 7

6 18. In your judgment, is the consumer capable of managing benefits on his or her behalf? 19. Please rate the consumer s sustained ability to perform the following work-related activities for 8 hours a day and 5 days a week. When doing so, use the following definitions for the rating terms. NONE SLIGHT MODERATE MARKED EXTREME UNKNOWN No impairment in this area Suspected impairment which marginally affects ability to function Impairment which imposed more than marginal, but less than serious affect on the ability to function An impairment which seriously affects ability to function Extreme impairment of ability to function over a sustained period of time Insufficient evidence A. Understand, remember, and carry out simple one or two step job instructions: B. Understand, remember, and carry out detailed but uncomplicated job instructions: C. Understand, remember, and carry out an extensive variety of technical and/or complex job instructions: D. Interact appropriately with supervisors and supervisory demands in a competitive job setting: E. Interact appropriately with co-workers in a competitive job setting: F. Interact appropriately with the public: G. Maintain concentration and attention: Psychological Impairment Report Page 6 of 7

7 20. Please rate the consumer s ability to perform the following activities: A. Care appropriately for his/ her own grooming and hygiene: B. Take care of their own activities of daily living, such as maintaining their living space: C. Initiate and complete activities necessary to support on-going daily living outside the home, such as doctor appointments: D. Travel without assistance outside of one s immediate living area: Form Completed By: Title: Date: Psychological Impairment Report Page 7 of 7

Residual Functional Capacity Questionnaire MENTAL IMPAIRMENT

Residual Functional Capacity Questionnaire MENTAL IMPAIRMENT Patient: DOB: Physician completing this form: Please complete the following questions regarding this patient's impairments and attach all supporting