HomeMy WebLinkAboutP-20-249 Pacific Forensic Psychology Associates.pdfGary Cornuelle Digitally signed by Gary Cornuelle
Date: 2020.06.30 13:25:46 -07'00'
Pacific Forensic Psychology Associates, Inc (DBA Sharper Future)
19230 Sonoma Highway, #200 Sonoma CA 95476
(707) 395-4500 N/A DPino@sharperfuture.com
Andrew Mendonsa, Psy.D. - CEO Tony Angelo, Psy.D. -President
Andrew Mendonsa,
Psy.D. - CEO
Digitally signed by Andrew
Mendonsa, Psy.D. - CEO
Date: 2020.06.30 10:26:40 -07'00'
Tony Angelo,
Psy.D. - President
Digitally signed by Tony Angelo,
Psy.D. - President
Date: 2020.06.30 10:26:53 -07'00'
Department of Social Services
Verification of Incapacity
GR8085 09-19-17 FileNET: Case Verification
Case No.:
Case Name:
SSN:
Date:
Worker No.:
The following information is needed to determine your eligibility for General Relief.
Please return this form by: .
Medical release authorization: I authorize my medical provider to release the following information:
Patient or Representative Signature Date
Health Care Provider: Please answer the questions below.
1. Does the patient have a physical or mental health condition that prevents or substantially reduces
their ability to engage in work or training?
No (please answer question 9 and sign the form)
Yes (please answer the following questions:
2. Onset date:
3. Expected
duration:
Temporary, expect to release patient for work on:
Permanent
4. Are they able to work? No, please go to no. 5 Yes, please answer the following questions:
Can perform limited full-time work limited part-time work
5. Describe how the physical and mental condition reduces their ability to engage in work:
6. Is the physical or mental condition primarily due to drug and/or alcohol abuse?
Yes No Unknown
7. Has the patient submitted a disability insurance application for completion?
Yes No Unknown
If yes, date submitted:
Department of Social Services
Verification of Incapacity
GR8085 09-19-17 FileNET: Case Verification
Case No.:
Case Name:
SSN:
Date:
Worker No.:
8. Is the patient receiving or seeking
treatment?
Yes No Unknown
9. I recommend a referral for: Mental Condition
Physical Condition
None
Comments:
Signature of Health Care Provider Date
Print Name
Title
Agency
Address
Phone No.
DEA No.