Prudential uses this four-page assessment when a claimant's absence from work is attributed to a psychiatric condition. The physician works through screening questions on restrictions, acute risk, workplace conflict and change from baseline, then rates readiness in areas such as self-care, structured work, social skills, memory, concentration and adaptability, giving restrictions, a treatment plan for restoring readiness and an anticipated date for each.
The treating physician or psychiatrist completes the assessment and signs the certification on page 4. The claimant's name and claim number go on every page.
Download the current version from the source each time; forms change without notice.
Psychiatric Work Readiness Assessment
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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The form allows signing and faxing back early if there are no psychiatric work restrictions, if the employee is acutely at risk or psychotic (with symptoms and plan), if return is possible once a workplace conflict resolves, or if function has not changed from an adequate baseline.
The instructions say a treatment plan should describe in detail the treatment methods that specifically target the psychiatric impairment. Each readiness area asks for that plan along with current restrictions and limitations and an anticipated date of work readiness.