Documentation for Psychological Disabilities

Comprehensive Documentation Should Include:

• Letterhead of diagnostician
• Date of last visit.
• DSM-IV Diagnosis/date of diagnosis
• Assessment procedures used to make the diagnosis
• Historical data taken into account in making the diagnosis.
• Major symptoms currently being manifested.
• Level of symptom severity (Global Assessment of Functioning)
• 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/to what degree it is limited. Please attach any test results, etc. you used to measure these limitations.
• Please discuss any current medications this individual is taking and the impact it has on the limitations described above.
• What is the treatment plan and prognosis (expected duration).
• Signature of individual with credentials to make the above diagnosis