Disability/Medical Leave/FMLA Form Step 1 of 12 8% Patient InformationPatient's Name:(Required) First Last Patient's Date of Birth:(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Current Age:(Required) Gender:(Required) Male Female Other Martial Status:(Required) Select One ... Single Married Separated Divorced Domestic Partners Other Home Address:(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone:Mobile Phone:(Required)Email Do you wish for us to use this email address to communicate with you? Yes No While convenient, the use of regular email may not be secure.My primary IHG Clinician is:(Required) Nirav Bigelow PhD, PsyD Christopher Bojrab, MD Andrew Brothers, PhD Deborah Bykowski, PMHNP-BC Deborah Carpenter, PMHCNS-BC Kathleen Chesterfield, LMFT, CMT Katherine (Katie) Clendenen, LMHC Beili Dong, MD Jenna Doyle, LMHC Christina Falink, LCSW Corey Falink, LMHC Tyler Flaningham, MD Jessica Fogle, LCSW Elizabeth Goebel, LMHC Marcy Haboush, LCSW Kirsten Hammersley, PMHNP-BC Marabeth Holland, LMHC Beverly Inman-Dunigan, LCSW Elizabeth Irick, LMHC Shiela Irick, MD Jennifer Jansen, LCSW Robert Jeffries, PhD Rich Jones, PhD Nancy Jungemann, PMHNP-BC Kim Keller, LMHC Seth Kleiman, LMHC Kourtney Klepfer, LCSW Maryann Lake, LCSW Bethany Littrell, LMHC Danita Lively, MD Barbara Logan, PMHNP-BC Darrin Mangiacarne, DO Christine Miller, DO Scott Minnich, MSW, LSW Sanjay Mishra, MD Laurie Moyer, LCSW, ATR Jennifer Myers, LCSW Shaunna Norris, LCSW Jill Oliver, PMHCNS-BC Terry Parrish, MD Tina Ramseur, LMHC Jane Rapinchuck MD Michelle Rinzel, LCSW Mary Roth, LCSW Carrie Schaefer, LCSW Camille Sexton-Villalta, PhD Dan Shelpler, PMHNP-BC Jim Shoot, MD Francia Siler, LCSW Jenn Stepic-Wenzel, LMHC Michael Webber, MD Steve Wilson, PMHCNS-BC Polly Westcott, PsyD Other/Not Listed Employer's InformationEmployer's Name: Employer's Address: Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact Person at Employer: First Last Contact Person's Phone: Disability Insurance InformationDisability Insurance Name: Note: If Social Security, enter Social Security DisabilityDisability Insurance Address: Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact Person at Disability Insurance: First Last Contact Person's Phone at Disability Insurance:Disability Insurance Company's Phone:Disability Insurance Company's Fax: NoticeWe are frequently asked to comment on a patient’s degree of psychiatric impairment and level of functioning. This is often for the purposes of determining his or her ability to return to work or his or her eligibility for some type of disability benefit. Unlike physical impairments, it is very difficult to quantify the degree of impairment based on psychiatric symptoms. Without objective measures, we are forced to rely largely on the patient’s description of their symptoms and the degree to which they feel their level of function is restricted. If the patient is currently involved in counseling/therapy, it may be useful to obtain additional information from the patient's therapist as well as they likely see the patient on a more frequent basis. It is often difficult to determine the length of the period of disability and the extent to which the patient could return to partial duties. If a patient is suffering symptoms severe enough to justify a medical or personal leave or to receive disability benefits, they would likely benefit from an increased level of care. If a patient fails to respond to traditional outpatient care (medication management and perhaps individual psychotherapy) it would be reasonable for the patient to receive more frequent care, a partial hospital level of care, day treatment, or an intensive outpatient program. It may also be appropriate to refer the patient for vocational rehabilitation for the purposes of a more comprehensive evaluation of their level of function, treatment to allow them to return to their occupation, or retraining for another occupation. Please Note: This form will be attached to your disability paperwork as part of the documentation required to facilitate your application for disability/medical leave. ALSO: IF YOU ARE UNABLE TO RETURN TO WORK/SCHOOL BY THE DATE ORIGINALLY SUBMITTED, IT IS YOUR RESPONSIBILITY TO CONTACT OUR OFFICE AND YOUR EMPLOYER/SCHOOL IN ADVANCE OF THE ORIGINAL DATE. WE WILL BE UNABLE TO EXTEND YOUR MEDICAL LEAVE IF YOU REQUEST THIS ON OR AFTER THE ORIGINAL RETURN TO WORK/SCHOOL DATE. Description of the Nature of the DisabilityPLEASE NOTE! This section is critically important to your application. It is your opportunity to provide the person reviewing your application with a picture of how you are feeling and functioning on a daily basis. Simply listing a few symptoms is not likely to provide them with the information they need to make a decision regarding your application. Keep in mind that the information that we provide on your behalf is limited to our observations about your status when we see you in the office, so it is up to you to provide a narrative that explains to the reviewer your current situation and circumstances.Please explain the reason that you are seeking/continuing disability/medical leave at this time:(Required)(what symptoms are you experiencing and how do these symptoms prevent you from being able to do your job)In the space below, please provide a description of the type of work you do:(Required)What have you tried to do to address these symptoms so far?(Required)Approximately when did this current episode begin or start to worsen?(Required) When was your first missed day of work?Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920What is the start date of your disability leave?(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920What date is the projected end of your disability leave?Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Please list the days of work which you have missed or have worked less than a full day as a result of the current issue since the last time you submitted a report.(Required)Please list the name(s) of all the physician(s) or other clinicians who you are seeing including their address, phone, and fax numbers.(Required)Do you think that you would be able to perform your job duties in an alternative work setting? Yes No If so, in what alternative work setting would you be able to perform your job duties? What would need to be different in order for you to do your job at this time?Disability or medical leave is typically intended to provide the opportunity to pursue more aggressive forms of treatment. It is usually the expectation of an employer that the patient be involved in active, routine care on an ongoing basis. If granted this leave, how will you use your time to prepare to return to work? (check all that apply)(Required) Working with an individual therapist Attending group therapy Participating in an intensive outpatient program (IOP) Participating in a partial hospitalization program (PHP) Being treated as in inpatient in the hospital Taking prescription medication as prescribed Other What type of leave are you requesting? (check all that apply)(Required) Time off work for the purposes of attending scheduled appointments with my physician or therapist Time off work in order to care for a family member A continuous leave of absence for the period of time specified below The ability to work on a daily basis, but for a reduced number of hours An intermittent leave of absence due to flare up of symptoms (specify days per month below) For a CONTINUOUS leave of absence, what is your estimate for the amount of time that you will need to be on leave? For a REDUCED NUMBER OF DAILY HOURS, please indicate the number of hours you feel capable of working on an average day. For an INTERMITTENT leave of absence, please list the number of days per month that you think that you may require to be off work. Symptom ChecklistSymptom Checklist:(Required) Addiction ADD/ADHD diagnosed or suspected Anger Anxiety Appetite Decreased Appetite Increased Compulsions Concentration Impairment Constipation Depressed Mood Destruction of property Diarrhea Dizziness Excessive Sweating Fatigue/Tiredness Fear Feelings Of Guilt Feelings Of Hopelessness Gambling excessively Hallucinations Impaired family relationships Impaired function at school Impaired function at work Impulsivity Inability to enjoy normal activities Indecisiveness Irritability Loneliness Memory impairment Mood swings Nausea Obsessive compulsive symptoms Overuse/misuse of alcohol Pain - back Pain - gastrointestinal Pain - general Pain - headache Pain - lower extremities Pain - shoulder Pain - upper extremities Panic attacks Paranoid thoughts Racing thoughts Restlessness Self harm (cutting, burning, hitting) Sexual difficulties Shakiness/tremulousness Shopping/spending excessively Sleep - problems falling asleep Sleep - problems staying asleep Sleep - waking up too early Sleep - not refreshing Suicidal thoughts Suicide plan Suicide attempt Tearfulness Violence towards others Weight gain Weight gain Other PHQ-9 Depression Rating ScaleOver the last 2 weeks (14 days), how often have you been bothered by any of the following problems?Little interest or pleasure in doing things:(Required) 0 - Not at all 1 - Several days 2 - More than half of the days 3 - Nearly every day Feeling down, depressed, or hopeless:(Required) 0 - Not at all 1 - Several days 2 - More than half of the days 3 - Nearly every day Trouble falling asleep or staying asleep, or sleeping too much:(Required) 0 - Not at all 1 - Several days 2 - More than half of the days 3 - Nearly every day Feeling tired or having little energy:(Required) 0 - Not at all 1 - Several days 2 - More than half of the days 3 - Nearly every day Poor appetite or overeating:(Required) 0 - Not at all 1 - Several days 2 - More than half of the days 3 - Nearly every day Feeling bad about yourself or that you are a failure or have let yourself or your family down:(Required) 0 - Not at all 1 - Several days 2 - More than half of the days 3 - Nearly every day Trouble concentrating on things such as reading the newspaper or watching television:(Required) 0 - Not at all 1 - Several days 2 - More than half of the days 3 - Nearly every day Moving or speaking so slowly that other people have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual:(Required) 0 - Not at all 1 - Several days 2 - More than half of the days 3 - Nearly every day Thoughts that you would be better off dead, or of hurting yourself in some way:(Required) 0 - Not at all 1 - Several days 2 - More than half of the days 3 - Nearly every day GAD-7 Anxiety Rating ScaleOver the last 2 weeks (14 days), how often have you been bothered by any of the following problems?1. Feeling nervous, anxious, or on edge:(Required) 0 - Not at all 1 - Several days 2 - More than half of the days 3 - Nearly every day 2. Not being able to stop or control worrying:(Required) 0 - Not at all 1 - Several days 2 - More than half of the days 3 - Nearly every day 3. Worrying too much about different things:(Required) 0 - Not at all 1 - Several days 2 - More than half of the days 3 - Nearly every day 4. Trouble relaxing:(Required) 0 - Not at all 1 - Several days 2 - More than half of the days 3 - Nearly every day 5. Being so restless that it's hard to sit still:(Required) 0 - Not at all 1 - Several days 2 - More than half of the days 3 - Nearly every day 6. Becoming easily annoyed or irritable:(Required) 0 - Not at all 1 - Several days 2 - More than half of the days 3 - Nearly every day 7. Feeling afraid as if something awful might happen:(Required) 0 - Not at all 1 - Several days 2 - More than half of the days 3 - Nearly every day Epworth Sleepiness ScalePlease indicate how likely it would be for your to nod off or fall asleep during the following activities:Sitting and reading:(Required) 0 - Would never fall asleep 1- Slight chance of falling asleep 2 - Moderate chance of falling asleep 3 - High chance of falling asleep Watching television:(Required) 0 - Would never fall asleep 1- Slight chance of falling asleep 2 - Moderate chance of falling asleep 3 - High chance of falling asleep Sitting inactive in a public place for example a theater or in a meeting:(Required) 0 - Would never fall asleep 1- Slight chance of falling asleep 2 - Moderate chance of falling asleep 3 - High chance of falling asleep As a passenger riding in a car for an hour:(Required) 0 - Would never fall asleep 1- Slight chance of falling asleep 2 - Moderate chance of falling asleep 3 - High chance of falling asleep Lying down to rest in the afternoon:(Required) 0 - Would never fall asleep 1- Slight chance of falling asleep 2 - Moderate chance of falling asleep 3 - High chance of falling asleep Sitting and talking to someone:(Required) 0 - Would never fall asleep 1- Slight chance of falling asleep 2 - Moderate chance of falling asleep 3 - High chance of falling asleep Sitting quietly after lunch (without alcohol):(Required) 0 - Would never fall asleep 1- Slight chance of falling asleep 2 - Moderate chance of falling asleep 3 - High chance of falling asleep Driving in a car, while stopped in traffic(Required) 0 - Would never fall asleep 1- Slight chance of falling asleep 2 - Moderate chance of falling asleep 3 - High chance of falling asleep Current MedicationsPlease list each medication, vitamin, supplement you are currently taking including the name, strength, number, and how often you take it during the day:(Required)Please list one (1) medication per line. WHODAS 2.0(World Health Organization Disability Assessment Schedule)For each item, select the degraded of difficulty you are having accomplishing the listed task.Concentrating on doing something for 10 minutes?(Required) 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme/Can't Do Remembering to do important things?(Required) 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme/Can't Do Analysing and finding solutions to problems in day-to-day life?(Required) 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme/Can't Do Learning a new task, for example, learning how to get to a new place?(Required) 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme/Can't Do Generally understanding what people say?(Required) 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme/Can't Do Starting and maintaining a conversation?(Required) 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme/Can't Do Standing for long periods such as 30 minutes?(Required) 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme/Can't Do Standing up from sitting down?(Required) 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme/Can't Do Moving around inside your home?(Required) 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme/Can't Do Getting out of your home?(Required) 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme/Can't Do Walking a long distance such as a kilometer [or equivalent]?(Required) 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme/Can't Do Washing your whole body?(Required) 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme/Can't Do Getting dressed?(Required) 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme/Can't Do Eating?(Required) 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme/Can't Do Staying by yourself for a few days?(Required) 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme/Can't Do Dealing with people you do not know?(Required) 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme/Can't Do Maintaining a friendship?(Required) 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme/Can't Do Getting along with people who are close to you?(Required) 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme/Can't Do Making new friends?(Required) 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme/Can't Do Sexual activities? 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme/Can't Do Taking care of your household responsibilities?(Required) 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme/Can't Do Doing most important household tasks well?(Required) 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme/Can't Do Getting all the household work done that you needed to do?(Required) 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme/Can't Do Getting your household work done as quickly as needed?(Required) 1 - None 2 - Mild 3 - Moderate 4 - Severe 5 - Extreme/Can't Do Please use this field to attach a file to your questionnaireMax. file size: 128 MB.
