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Author Topic: SSA/VA Self-Report Template  (Read 12820 times)

digiview3

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SSA/VA Self-Report Template
« on: April 10, 2012, 03:56:18 pm »
Below is a mental self-report that can be used for SSA/VA and can be modified for Physical disabilities as well:

My Medical and Mental Disorders cause the following problems:

I understand that the Social Security Administration uses DSM-IV to determine if an applicant has a particular mental disability.

I have been diagnosed by the Veterans Administration with Post Traumatic Stress Disorder (PTSD). While I understand the SSA is not required to accept the diagnosis of the VA I wish to bring the following to your attention:

Under CFR 20, Appendix 1 to Subpart P, paragraph 12.06 (List of Impairments) Anxiety Related Disorders (the DSM-IV has PTSD listed under a "Stress Response" category, which comes under their "anxiety disorder" category) the List of Impairments says:

"A. Medically documented findings of at least one of the following, referring to items 1 through 5 under "A"
Your # 1(d) corresponds directly with item d (4) in section 309.81, "Anxiety Disorders", of DSM-IV.
Your # 2 corresponds directly with item c (2) in section 309.81, "Anxiety Disorders", of DSM-IV.
Your # 5 corresponds directly with item b (1) in section 309.81, "Anxiety Disorders", of DSM-IV.
As you can see PTSD fulfills THREE of the requirements, not just ONE.

AND

B. Resulting in at least two of the following:
Your # 2 corresponds directly with item c (2) in section 309.81, "Anxiety Disorders", of DSM-IV.
Your # 3 corresponds directly with item d (3) in section 309.81, "Anxiety Disorders", of DSM-IV.
Your # 4 corresponds directly with item d (2) & d (3) in section 309.81, "Anxiety Disorders", of DSM-IV.

PTSD fulfills THREE requirements, not just two.
Your attention is invited to 20 CFR 303.1520 (d) which states, "If you have an impairment(s) which meets the duration requirement and is listed in appendix 1 OR is equal to a listed impairment(s), we will find you disabled without considering your age, education, and work experience."
The introduction to the List of Impairments says "The listings are so constructed that an individual with an impairment(s) that meets or is equivalent in severity to the criteria of a listing could not reasonably be expected to do any gainful activity" therefore a residual functional capacity (RFC) evaluation should not be required.
If you do not agree with the "List of Impariments" data presented above please provide the reason for disagreement."

Post-traumatic Stress Disorder (From SSDI Blue Book: Anxiety Disorders 12.06): I served with the US Air Force in Minot, ND and was wounded suffering Chronic Post-traumatic Stress Disorder due to being sexually assaulted/raped on two occasions during my military service.
Occupational Limitations: For 8 years I have had continuous nightmares and night terrors, startled responses, hypervigilance, flashbacks, reliving experiences, intrusive thoughts, sleep disturbance, mood disturbances (anger and irritability, daily panic disorder, anxiety, chronic fatigue, and major depression), restriction of affect, poor social interactions, immediate and short-term memory problems, and reactivity to events that include images and recollections of my time in service.

I also experience marked avoidant behaviors and find isolation more preferable to interactions with others. I tend to avoid crowds, people and situations that do not provide me an opportunity to escape. I have a sense of detachment from others and do not seek to interact with anyone. I have come to realize that I can no longer work in my profession because of these issues and my preoccupation with intrusive thoughts concerning my experiences in service. Intrusive thoughts have been present since I was medically discharged from service in 2005 and have grown in intensity. I constantly ruminate about events and my experiences in service. These experiences have progressively become worse over the past two years inhibiting my ability to perform my professional functions and responsibilities.

In my attached recent Compensation & Pension Exam dated 02/28/11 from the Veterans Administration in(STATE AND DOCTOR), MD states "It is not felt she is currently clinically stable enough to hold down any form of substantive gainful employment at this time.”  The Global Adaptive Functioning is 40 (assigned for impairment in reality testing or communication or major impairment in several areas such as work or school, family relations, judgment, thinking, or mood)."

More often than not, I mix things up and have to continually correct these errors. Recently, I have gotten angry with people causing them stress and negative feelings as a result. It is difficult to perform my professional responsibilities out of fear that I may make a critical mistake causing harm to another individual. I have found that participating in my professional employment exacerbates my stress, mental disorders generating panic attacks, stress, depressive episodes and leads me to engage in my bulimic behaviors.

TREATMENT: My treatment began as early as 2005 by a DOCTOR AND LOCATION for problems related to Severe Depression and Bulimia and was given a prescription of Prozac. Later in 2007, I received treatment from DOCTOR AND LOCATION  in EMDR ( Eye Movement Desensitization and Reprocessing) therapy for PTSD resulting from trauma and Eating Disorder group therapy. In 2009 I attended LOCATIONS for 4 months until no longer covered by insurance where I had to withdraw from treatment. In 2010 I relapsed and was admitted to a partial hospitalization/inpatient treatment at PLACE AND LOCATION for 1 month for my Bulimia Nervosa.

Currently, I attend outpatient mental health treatment at the VA Medical Center in LOCATION treated by DOCTOR and am prescribed 80mg of Fluoxetine for depression, 150mg of Bupropion 2x a day, 30mg of Buspirone 2x a day for anxiety/PTSD, 20mg of Methylphenidate 3x a day for ADHD symptoms resulting from PTSD, 10mg of Cetirizine for chronic hives resulting from stress, 40mg of Omeprazole for chronic acid reflux resulting from my Bulimia and 50mg of Trazadone as needed for sleep. I also see NAME, MFT at PLACE AND LOCATION for counseling.

Major Depression Disorder (Affective Disorders 12.04): I have a history of depression secondary to Post-traumatic Stress Disorder.

Occupational Limitations: I suffer from Major Depression comorbid with Post-traumatic Stress Disorder and Bulimia Nervosa. I have loss of interest in activities, psychomotor agitation, extreme fatigue, feelings of guilt and hopelessness, sadness more days than not, and sleep disturbance. It causes difficulty in concentration and persistence, difficulty maintaining social functioning, and restriction of daily activities. These symptoms have been diagnosed by several physicians in the past, and currently by the Veterans Administration.

Treatment: I currently receive treatment for Major Depression at the VA Medical Center in LOCATION AND DOCTOR. I am prescribed Fluoxetine 80mg once daily. I also receive 150mg of Bupropion 2x a day which is also an antidepressant.

Panic Disorder with Agoraphobia and Generalized Anxiety Disorder(Anxiety Disorders 12.06): I have Panic disorder with Agoraphobia and Generalized Anxiety Disorder comorbid to Post-traumatic Stress Disorder.

Occupational Limitations: I suffer panic attacks daily with severe bouts of panic disorder four or five times weekly. I have motor tension, fatigue, anticipatory anxiety, hypervigilance, and hyperactivity of mind and body. I have significant fear of reliving my experiences in service or when I observe things that remind me of my trauma in service, I have panic attacks and struggle with anxiety/restlessness combined with a desire to escape. At times struggle with agoraphobia from fear of future trauma and this restricts my ability to perform work related functions because of constant ruminations of impending doom, feelings as if bad things will happen, and feelings as if I were still in service. This anxiety is unmanageable and a source of continuous uncertainly and fear.

I prefer isolation to social activities and restrict my movements to around home and on very rare occasions venture out with my spouse. I have problems with concentration, persistence, and often fail to complete tasks in a timely fashion. I tend to withdraw from situations where there is no possibility of escape, or when I am uncomfortable. If the situation reminds me of my service experiences, I seek the safety of my home.

Treatment: I receive treatment from the VA Medical Center in LOCATION AND DOCTOR. I am prescribed Alprazolam 1 mg five times daily for Panic Disorder with Agoraphobia and Generalized Anxiety Disorder.  Bulimia nervosa is an eating disorder characterized by binge eating and purging or consuming a large amount of food in a short amount of time, followed by an attempt to rid oneself of the food consumed, usually by purging (vomiting) and/or by laxative, diuretics or excessive exercise.
Treatment:  I have been hospitalized twice due to my Bulimia at PLACE AND LOCATION in 2009 and 2010 and am currently being treated by NAME, MFT at LOCATION AND PLACE.

In conclusion, I’m currently service-connected and rated by the Veterans Administration with increase pending in decision phase that I expect to be rated at minimum 70% by the Veterans Administration with a designation of Individual Unemployability. Because of this designation, it is deemed that my medical and mental disorders will not improve in the next 12 months and will likely continue for my lifetime. I am 27-years of age and contend my disabilities are progressing and will not improve. My medical and mental disorders have progressively worsened to the level that I can no longer function in any occupation that I have worked in for many years. Therefore, I request that my claim for SSDI be approved.

John - Fighting for my Wife

Me: SSDI Approved 12/2008 Wife: SSDI Approved Bench Decision ALJ Level 06/19/13
Me: Medi-Cal/Medicaid Approved 09/2010 Wife: Pending
Me: Medicare Approved 01/2011 Wife: Approved

Goosey

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Re: SSA/VA Self-Report Template
« Reply #1 on: September 15, 2013, 07:18:42 pm »
This is very helpful.  The thing is this - the report sounds like it was written by a professional, not a claimant (unless the claimant happens to be a psychologist or psychiatrist).  I guess it doesn't matter but I am going to change some of the technical, "official", terminology and use my own words.

Is this something like an added letter for the file, stuff that's not covered in the Adult Function Report and the Application and Disability Report?

Thank you.
My Own Time Line:
August 29, 2013: Applied online.
September 27, 2013: Claim sent to DDS
October 1-17, 2013: GOVERNMENT SHUTDOWN
October 22, 2013: DDS request 3 forms
Oct 29, 2013: Mailed forms
January 26, 2014: Consultative exam scheduled

digiview3

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Re: SSA/VA Self-Report Template
« Reply #2 on: October 02, 2013, 06:28:33 pm »
Goosey we submitted the self-report for SSDI and VA claim and won both.
John - Fighting for my Wife

Me: SSDI Approved 12/2008 Wife: SSDI Approved Bench Decision ALJ Level 06/19/13
Me: Medi-Cal/Medicaid Approved 09/2010 Wife: Pending
Me: Medicare Approved 01/2011 Wife: Approved