Documentation for Psychological Disabilities
Comprehensive Documentation Should Include:
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Letterhead of diagnostician
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Date of last visit.
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DSM-IV Diagnosis/date of diagnosis
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Assessment procedures used to make the
diagnosis
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Historical data taken into account in making
the diagnosis.
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Major symptoms currently being manifested.
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Level of symptom severity (Global Assessment
of Functioning)
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A mental impairment rises to the level of a
disability when it substantially limits one or more major life activities of
the individual. Please indicate what major life activity is currently
impacted and how and to what degree it is limited. Please attach any test
results, etc. used to measure these limitations.
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Please discuss any current medications this
individual is taking and the impact it has on the limitations described
above.
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What is the treatment plan and prognosis
(expected duration).
Signature of individual
with credentials to make the above diagnosis
Last updated
Tuesday, February 21, 2006 10:03 AM