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At Counseling Institute of Atlanta, our team of bilingual experts would be more than glad to help you to complete a comprehensive and detailed clinical evaluation for you disability application process.

The Social Security Administration provides a guideline of information to be included in a mental health evaluation. For more information you can review its website www.ssa.gov

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Let’s schedule an appointment

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Mental Disorders

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  1. General
    1. Identify claimant
      1. Include the claimant’s SSN or other non-SSN case identifier, and
      2. Indicate that the claimant provided proof of identity by showing a valid and current government photo ID (e.g., U.S. State-issued driver’s license, U.S. State-issued non-driver identity card, U.S. passport, U.S. military ID, student or school ID, etc.) or
      3. Provide a physical description of the claimant, to help ensure that the person being examined is the claimant, except if the treating source is the CE source.
    1. Longitudinal medical history
      1. Cite the medical records and any other documents reviewed during the course of the evaluation.
      2. Identify the person(s) providing the oral medical history and an assessment of the accuracy of such information.
  2. Current Medical History – Describe and discuss:
    1. The primary symptom(s) alleged as the reason for not working. This discussion must include:
      1. History of the onset and progress of the disorder;
      2. The claimant’s statement of current symptom(s);
      3. Type(s) and effect(s) of any treatment;
      4. Claimant’s typical daily activities.
    2. Dates and results of relevant hospitalizations, surgical operations, and diagnostic procedures.
    3. Past and current participation and success or failure in rehabilitation, group homes or half-way houses, inpatient or outpatient treatment.
  3. Past Medical History – Describe and discuss (when appropriate) other significant past illnesses, injuries, operations, and diagnostic procedures with dates of the events.
  4. Current Medication – List name, dose and frequency of medication(s); including both beneficial and adverse effects.
  5. Social and Family History – Include the following:
    1. Relevant information, including longitudinal history of relations with parents, family, peers, spouses, co-workers, etc.;
    2. Educational background (special education, college courses/degree, special vocational training);
    3. Relevant history of legal or occupational problems associated with the disorder;
    4. Involvement in hobbies and/or regular group activities (church, social clubs, participation in sports teams, etc.);
    5. A description of the claimant’s attempt(s) to return to work and the results (e.g., de-compensation, missed work due to inability to handle stress);
    6. Detailed longitudinal discussion of any history of alcohol, licit and illicit drug abuse, and comments on the effects of substance abuse on functioning; if there is no history of substance abuse, include a statement to that effect.
  6. Physical Examination – Describe and discuss (when appropriate):
    1.  General appearance, nutritional status, behavior (such as cooperativeness), any apparent abnormalities;
    2. General observations, including whether the claimant came to the examination alone or accompanied; distance and mode of transportation; and, if by automobile, who drove;
    3. General motor behavior, including involuntary movements, restlessness, and psychomotor retardation or agitation.
  7. Mental Status Evaluation – Include the following specific observations:
    1. Manner and approach to evaluation;
    2. Dress, grooming, hygiene and presentation;
    3. Mood and affect;
    4. Eye contact;
    5. Expressive/receptive language;
    6. Recall/memory, including working, recent and remote;
    7. Orientation in all 4 spheres;
    8. Concentration and attention;
    9. Thought processes and content;
    10. Perceptual abnormalities;
    11. Suicidal/homicidal ideation;
    12. Judgment/insight;
    13. Estimated level of intelligence.
  8. Interpretation of psychological and/or clinical testing. (If the interpretation is provided separately, the report sheet should state the interpreting medical source’s name and address)
    1. Identify the medical source (name and address) providing the formal interpretation of the psychological and/or clinical tests when that source is other than the individual signing the CE report.
    2. Provide interpretation of psychological and/or clinical testing results that takes into account, and correlates with, the history and examination findings.
  9. Additional Information – the report should also contain the following:
    1. A full multiaxial classification per American Psychiatric Association standard nomenclature as set forth in the most recent Diagnostic and Statistical Manual of Mental Disorders
    2. Prognosis and recommendations for treatment, if indicated. Also, recommendations for any other evaluation (for example, neurological examination), if needed
    3.  For claimants with intellectual impairment:
      1. Current documentation of IQ by a standardized, well-recognized, individually administered measure. Acceptable instruments will have a recent and representative normative sample of the target population, a mean of approximately 100 and standard deviation of approximately 15 in the general population, and cover a broad range of cognitive and perceptual-motor functions.
      2. Verbal IQ, Performance IQ, and Full Scale IQ scores, or their equivalents, together with the individual subtest scores.
      3. Interpretation of the scores and assessment of the validity of the obtained scores, indicating any factors that influenced the claimant’s attitude or degree of cooperation.
      4. Consistency of the obtained test results with the claimant’s educational, vocational, and social background.
      5. A comprehensive and detailed description of adaptive behavior in the areas of personal, social, academic, and occupational functioning during the developmental period.
  10. Medical source statement – Include the following:
    1. A statement regarding the nature and extent of the mental disorder.
    2. An assessment of the claimant’s abilities and limitations based on medical history, observations during examination, and results of relevant laboratory tests; and an opinion regarding the ability to:
      1. Understand, carry out, and remember instructions (both complex and one-two step);
      2. Sustain concentration and persist in work-related activity at reasonable pace;
      3. Maintain effective social interaction on a consistent and independent basis, with supervisors, co-workers, and the public; and
      4. Deal with normal pressures in a competitive work setting.
    3. If hazards should be avoided or limited (e.g., operating machinery due to medication side effect), specify which ones and why.
    4. Discussion of any apparent discrepancies in medical history or in examination findings and how discrepancies resolved.
    5. A statement regarding malingering, if applicable.
    6. A statement regarding the capability to manage funds.

The social Security Administration also provides information about a disability[/vc_column_text][vc_column_text css_animation=”fadeInLeft”]

Definition of Disability

For all individuals applying for disability benefits under title II, and for adults applying under title XVI, the definition of disability is the same. The law defines disability as the inability to engage in any substantial gainful activity (SGA) by reason of any medically determinable physical or mental impairment(s) which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.

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Disability in Children

Under title XVI, a child under age 18 will be considered disabled if he or she has a medically determinable physical or mental impairment or combination of impairments that causes marked and severe functional limitations, and that can be expected to cause death or that has lasted or can be expected to last for a continuous period of not less than 12 months.

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What is a “Medically Determinable Impairment”

To establish the existence of a medically determinable impairment, we need objective medical evidence from an acceptable medical source. Objective medical evidence means “signs, laboratory findings, or both”. We never establish a medically determinable impairment based on an individual’s statement of symptoms, a diagnosis, or a medical opinion.

Signs are defined as one or more anatomical, physiological, or psychological abnormalities that can be observed, apart from your statements (symptoms). Signs must be shown by medically acceptable clinical diagnostic techniques. Psychiatric signs are medically demonstrable phenomena that indicate specific psychological abnormalities, e.g., abnormalities of behavior, mood, thought, memory, orientation, development, or perception, and must also be shown by observable facts that can be medically described and evaluated.

Laboratory findings are defined as one or more anatomical, physiological, or psychological phenomena that can be shown by the use of medically acceptable laboratory diagnostic techniques. Diagnostic techniques include chemical tests (such as blood tests), electrophysiological studies (such as electrocardiograms and electroencephalograms).

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Let’s schedule an appointment

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