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2. State regulations require that persons receiving assistance work or participate in activities to prepare them for work unless they are physically or mentally incapable of working. Any information you provide is confidential by Maine State Statutes. The person named below has applied for General Assistance from the City of Westbrook.
4. First Name
5. Last Name
7. I, _______________________________________ hereby give my consent to the City of Westbrook General Assistance, 426 Bridge St., Westbrook, ME to receive any and all medical information from the named health provider.
   (Insert Name as Agreement)
9. To
10. Date
12. Client Name
13. Date of Birth
    Date of Birth
15. Client Address
17. City
18. State
19. Zip Code
21. This client of the GENERAL ASSISTANCE PROGRAM has stated they are presently disabled.
    
    In order to determine the eligibility of the above-named client to receive the assistance he/she is requesting, we require the following information:
23. 1) Nature and extent of the illness, disability or injury
25. 2)
27. In your opinion is the client able to work at a regular job/employment?

    1. Yes
    2. Yes (with limitations)
    3. No
28. How many hours per week should they work?
30. In your opinion is the client able to seek work/do job searches?

    1. Yes
    2. Yes (with limitations)
    3. No
31. In your opinion is the client able to attend school or classes?

    1. Yes
    2. Yes (with limitations)
    3. No
33. In your opinion is the client able to do City workfare?

    1. Yes
    2. Yes (with limitations)
    3. No
35. IF YES WITH LIMITATIONS, please state limitations, i.e. light duty, limited hours/days, restrictions on lifting, movement, standing, etc.
37. 3) If disabled, length of time he/she will be unable to work or perform items in accordance to 2?
    (If unknown at this time, give date of next evaluation)
39. 4) If disabled, in your opinion, would this client benefit from the services of the Department of Vocational Rehabilitation for retraining or education?
41. 5) In your opinion, is this client so disabled that he/she should apply for disability benefits?
43. 6) Does this illness or condition require medication?
    (If so, please specify)
45. 7) If client is not considered permanently disabled, what can this client do to help themselves become work-ready?
47. 8) Date you last evaluated this patient for this disability?
49. Additional information/comments, if any?
51. Doctor's Name
52. Doctor's Signature

    1. Agree

    (Select this box if you agree to the above statement)
54. Date
55. Agency
57. Any information you provide is confidential by Maine State Statute. We thank you for your cooperation. The information may be returned via the client or faxed to 1-877-722-3057 or mailed to: Westbrook Community Center, 426 Bridge St., Westbrook, ME 04092 Attn: General Assistance
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59. 1. Receive an email copy of this form.
60. Email address

    This field is not part of the form submission.

61. Submit

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