Include your name; your credentials, i.e., a board certified psychiatrist, a licensed psychologist, a psychiatry resident or a psychology intern, LCSW, or NP and circumstances under which you performed the examination, if applicable, i.e., under the close supervision of an attending psychiatrist or psychologist; include name of supervising psychiatrist or psychologist.

Signature:                        

Date:            

Signature of Supervising psychiatrist or psychologist:

Date:            


SOURCE: http://www.vba.va.gov/bln/21/Benefits/exams/disexm56.htm.



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