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When a diagnosis isn't enough, clear clinical documentation can help tell the whole story.

Disability claims and legal cases are often decided by people who have never met you. A focused clinical evaluation can translate symptoms, history, and functional limitations into clear professional documentation that attorneys, physicians, agencies, and other decision-makers can understand.

Call (919) 756-6210

Provided by Jamie E. Mills, LCSW, CIMHP, CCTP — Clinical Director · In-person assessment in Raleigh, NC or Telehealth Statewide in North Carolina

Our commitment: we provide accurate, independent clinical documentation — not advocacy disguised as an evaluation, a guaranteed disability rating, or a predetermined opinion. Our evaluations are clinical social work assessments conducted by a Licensed Clinical Social Worker; we do not provide psychological or neuropsychological testing, medical examinations, or medical opinions.

Professional Clinical Documentation

When mental-health symptoms affect someone's ability to work, function, maintain relationships, or participate fully in daily life, a diagnosis alone may not tell the whole story.

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Many of the people we see already have a diagnosis from a medical provider. What's missing is documentation of everything around it — the functional picture a decision-maker needs. Our evaluations complement your existing medical care: we take the time to assess and describe what a brief appointment can't.

We provide focused clinical evaluations and professionally written documentation describing:

  • Relevant symptoms and diagnoses​

  • Treatment history and clinical observations

  • Functional limitations

  • The relationship between symptoms and everyday functioning

  • Clinical recommendations, when appropriate

Clear, clinically grounded documentation can help attorneys, physicians, government agencies, employers, and other decision-makers understand the full impact of a person's mental-health condition.

Documentation may support:

VA disability claims

Social Security disability applications

Personal-injury and trauma-related legal cases

Employment or medical-leave requests

Coordination with physicians, attorneys, or other professionals

Who We Help

VA Disability Documentation

 

We can provide a clinical evaluation and summary of symptoms, history, and functional impairment for veterans pursuing a disability claim.

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This documentation may be used as supporting evidence or provided to a physician preparing a formal medical opinion

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.We do not advertise this service as a "nexus letter," and we cannot guarantee a particular disability rating or claim outcome.

Social Security Disability

 

We can document how mental-health symptoms affect areas such as:

 

Concentration and task completion

Attendance and consistency

Stress tolerance

Social functioning

Adaptation to workplace demands

The ability to sustain reliable employment

 

Our documentation serves as supporting evidence of symptom severity and functional impact. Social Security requires that a medically determinable impairment be established by an "acceptable medical source," such as a physician or licensed psychologist.

Legal & Personal-Injury Cases

 

When trauma, an accident, or another event has caused or worsened psychological symptoms, we can provide an assessment and clinical summary explaining the person's presentation, functional impact, treatment needs, and prognosis when clinically supportable.

Employment & Medical Leave

 

Documentation supporting FMLA requests, workplace accommodations, and medical-leave decisions — grounded in a clinical assessment and written for the decision-makers who will read it.

How the Service Works

1

We first determine whether the requested documentation is within our clinical scope.

2

The client completes an in-person clinical assessment at our Raleigh office.

3

Relevant records may be reviewed when needed.

4

The clinician prepares a professional clinical summary letter based on the available evidence.

5

With written authorization, the clinician may coordinate with an attorney, physician, or other appropriate professional.

Fees

Service

Clinical evaluation and summary letter

Additional consultation, record review, attorney communication, deposition, or legal participation

$350

$180 / hour

Routine FMLA or disability-related letters for established clients

$35–$40

Start with a scope call

Tell us what documentation you need and we'll first confirm it's within our clinical scope — before you schedule or pay for anything.

call (919) 756-6210

Service

Fee

What's included: the $350 fee covers the assessment and written clinical summary. It does not include extensive records review, testimony, completion of lengthy legal forms, or ongoing involvement in a case — those are billed at the hourly rate above. All documentation services are cash-pay; we do not bill insurance for evaluations or letters.

@2024 A member of Cannenta Wellness & Counseling Inc - A Nonprofit Mental Healthcare System

8601 Six Forks Rd, STE 400, Raleigh, NC 27615

(919) 756-6210

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