CLIENT’S NAME DATE OF BIRTH CLIENT ID
Psychological / Psychiatric Evaluation
• This form m ust be typed or com pleted using w ord processing softw are in order to be eligible for reim bursem ent.
• Attach all testing docum entation, including sub scores.
• A Mental Status Exam ination, follow ing 13-865 Guidelines, m ust be attached.
• Please ensure you are using the current version of the form , located here.
A. Client Inform ation
Impairment / symptoms claimed by client:
Records review ed:
B. Authorization to Release Inform ation
I authorize to release the follow ing information regarding my condition to the Department of
EXAMINING PROFESSIONAL’S NAME
Social and Health Services (DSHS). This release includes the contents of this evaluation as w ell as diagnostic testing or treatment
information concerning mental health, alcohol or drug use, sickle cell disease, and sexually transmitted disease, including HIV/AIDS (Chapter
70.02 Revised Code of Washington (RCW)) (42 Code of Federal Regulations (CFR) part 2).
An authorization w as obtained by a separate release of information consent form, DSHS 14-012.
CLIENT’S SIGNATURE DATE
C. Clinical Interview
1. Psychosocial History:
2. Medical / Mental Health Treatment History:
3. Educational / Work History:
4. Substance Use History (include any current substance use disorder diagnosis and related symptoms in Sections D and E):
5. Instrumental Activities of Daily Living (include a description of the client’s activities and routines on a typical day):
6. Other:
D. Clinical Findings
1. List all mental health symptoms that affect the individual’s ability to w ork:
SYMPTOM DESCRIPTION (INCLUDE SEVERITY AND FREQUENCY)
E. Assessm ent / Diagnosis
1. List each applicable diagnosis from the current Diagnostic and Statistical Manual of Mental Disorders (DSM) and describe how it is
supported by available objective evidence:
DIAGNOSIS ONSET DATE
PSYCHOLOGICAL / PSYCHIATRIC EVALUATION
DSHS 13-865 (REV. 08/2018)
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F. Medical Source Statem ent
Severity Ratings:
“None or Mild” means no significant limitation on the ability to perform the activity.
“Moderate” means a significant limitation on the ability to perform the activity.
“Marked” means a very significant limitation on the ability to perform the activity.
“Severe” means the inability to perform the activity in regular competitive employment or outside of a sheltered w orkshop.
Rate the follow ing basic w ork activities based on the individual’s ability to sustain the activity over a normal w orkday and w orkw eek on an
ongoing, appropriate, and independent basis.
1. Basic Work Activity: Severity:
None Severity
or Mild Moderate Marked Severe Indeterminate
a. Understand, remember, and persist in tasks by follow ing
very short and simple instructions...................................................................
b. Understand, remember, and persist in tasks by follow ing detailed
instructions ......................................................................................................
c. Perform activities w ithin a schedule, maintain regular attendance, and
be punctual w ithin customary tolerances w ithout special supervision...........
d. Learn new tasks..............................................................................................
e. Perform routine tasks w ithout special supervision..........................................
f. Adapt to changes in a routine w ork setting.....................................................
g. Make simple w ork-related decisions................................................................
h. Be aw are of normal hazards and take appropriate precautions.....................
i. Ask simple questions or request assistance...................................................
j. Communicate and perform effectively in a w ork setting .................................
k. Maintain appropriate behavior in a w ork setting ..............................................
l. Complete a normal w ork day and w ork w eek w ithout interruptions
from psychologically based symptoms............................................................
m. Set realistic goals and plan independently.......................................................
2. Rate the overall severity based on the combined impact of all diagnosed mental impairments.
Overall Severity Rating ....................................................................................
G. Substance Use
1. Are the effects on basic w ork activities primarily the result of a substance use disorder? Yes No Please explain.
2. Would the effects on basic w ork activities persist follow ing 60 days of sobriety? Yes No If no, how w ould they change?
3. Is a chemical dependency assessment or substance use treatment recommended? Yes No
H. Prognosis / Plan
1. Duration (length of time the individual w ill be impaired w ith available treatment): months.
2. Is a protective payee recommended due to mismanagement of funds? Yes No
3. Would vocational training or services minimize or eliminate barriers to employment? Yes No Partially Please
explain.
4. Additional treatment recommendations:
PSYCHOLOGICAL / PSYCHIATRIC EVALUATION
DSHS 13-865 (REV. 08/2018)
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The inform ation you provide m ay be released to the individual you evaluate and is subject to Washington State Public
Disclosure law s.
NAME AND SPECIALTY OF EXAMINING PROFESSIONAL
Return this report to:
TELEPHONE NUMBER (INCLUDE AREA CODE)
STREET ADDRESS
CITY STATE ZIP CODE
EXAMINATION DATE TESTING DATE (IF DIFFERENT FROM EXAMINATION DATE)
EXAMINING PROFESSIONAL’S SIGNATURE* / TITLE DATE
Mental Status Exam
Part 1. Observation Detail: Com plete each category below for all clients.
A. Appearance:
B. Speech:
C. Attitude and Behavior:
D. Mood:
E. Affect:
Part 2. Additional Detail: If not w ithin norm al lim its in each category below , provide observation detail.
A. Thought Process and Content; w ithin normal limits? Yes No; if no, provide detail below :
B. Orientation; w ithin normal limits? Yes No; if no, provide detail below :
C. Perception; w ithin normal limits? Yes No; if no, provide detail below :
D. Memory; w ithin normal limits? Yes No; if no, provide detail below :
E. Fund of Know ledge; w ithin normal limits? Yes No; if no, provide detail below :
F. Concentration; w ithin normal limits? Yes No; if no, provide detail below :
G. Abstract Thought; w ithin normal limits? Yes No; if no, provide detail below :
H. Insight and Judgment; w ithin normal limits? Yes No; if no, provide detail below :
PSYCHOLOGICAL / PSYCHIATRIC EVALUATION
DSHS 13-865 (REV. 08/2018)
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