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Doctor’s Statement

  1. 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.

  2. (Insert Name as Agreement)

  3. 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:

  4. 2)

  5. In your opinion is the client able to work at a regular job/employment?

  6. In your opinion is the client able to seek work/do job searches?

  7. In your opinion is the client able to attend school or classes?

  8. In your opinion is the client able to do City workfare?

  9. (If unknown at this time, give date of next evaluation)

  10. (If so, please specify)

  11. Doctor's Signature

    (Select this box if you agree to the above statement)

  12. 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

  13. Leave This Blank:

  14. This field is not part of the form submission.