Washington DSHS uses this evaluation to decide whether a client's mental impairment causes incapacity for Aged, Blind or Disabled cash assistance or a Housing and Essential Needs referral. The examining psychologist, psychiatrist or other qualified professional documents a clinical interview, symptoms, DSM diagnoses and a medical source statement rating 13 basic work activities, then gives a prognosis and estimated duration of impairment.
A licensed psychologist, psychiatrist or other qualified mental health professional paid by DSHS completes the whole evaluation and signs it. The client signs the Section B authorization, or authorizes release on the separate DSHS 14-012 consent.
Download the current version from the source each time; forms change without notice.
Psychological / Psychiatric Evaluation
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Yes. The form states it must be typed or completed using word processing software to be eligible for reimbursement. DSHS publishes a Word version for this purpose. Attach all testing documentation, including subscores, and a mental status exam that follows the 13-865 Guidelines.
The 13-865 Guidelines require detailed observations of appearance, speech, attitude and behavior, mood and affect for every client. If not within normal limits, the exam must also detail thought process and content, orientation, perception, memory, fund of knowledge, concentration, abstract thought, and insight and judgment.
The form warns that the information may be released to the individual evaluated and is subject to Washington public disclosure laws. The client's authorization covers mental health, substance use, sickle cell disease and sexually transmitted disease information when it is part of the evaluation.