Mental Disorders Disability Benefits Questionnaire
Released March 2021
Updated on: April 1, 2020 ~v20_1
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MENTAL DISORDERS (OTHER THAN PTSD AND EATING DISORDERS)
DISABILITY BENEFITS QUESTIONNAIRE
NAME OF PATIENT/VETERAN PATIENT/VETERAN'S SOCIAL SECURITY NUMBER
If the Veteran currently has one or more mental disorders that conform to DSM-5 criteria, provide all diagnoses:
1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH A MENTAL DISORDER(S)?
NOTE: In order to conduct an initial examination for mental disorders, the examiner must meet one of the following criteria: a board-certified or board-eligible
psychiatrist; a licensed doctorate-level psychologist; a doctorate-level mental health provider under the close supervision of a board-certified or board-eligible
psychiatrist or licensed doctorate-level psychologist; a psychiatry resident under close supervision of a board-certified or board-eligible psychiatrist or licensed
doctorate-level psychologist; or a clinical or counseling psychologist completing a one-year internship or residency (for purposes of a doctorate-level degree) under
close supervision of a board-certified or board-eligible psychiatrist or licensed doctorate-level psychologist.
In order to conduct a review examination for mental disorders, the examiner must meet one of the criteria from above, OR be a licensed clinical social worker
(LCSW), a nurse practitioner, a clinical nurse specialist, or a physician assistant, under close supervision of a board-certified or board-eligible psychiatrist or licensed
doctorate-level psychologist.
This Questionnaire is to be completed for both initial and review mental disorder(s) claims.
SECTION I: DIAGNOSIS
NOYES
MENTAL DISORDER DIAGNOSIS #1
ICD CODE:
COMMENTS, IF ANY:
IF ADDITIONAL DIAGNOSES, LIST USING ABOVE FORMAT:
NOTE: If the Veteran has a diagnosis of an eating disorder, complete the Eating Disorders Questionnaire, in lieu of this questionnaire.
NOTE: If the Veteran has a diagnosis of PTSD, the Initial PTSD Questionnaire must be completed by a VHA staff or contract examiner in lieu of this questionnaire.
ICD CODE:
COMMENTS, IF ANY:
1B. MEDICAL DIAGNOSES RELEVANT TO THE UNDERSTANDING OR MANAGEMENT OF THE MENTAL HEALTH DISORDER (to include TBI):
1. DIAGNOSIS
MENTAL DISORDER DIAGNOSIS #2 ICD CODE:
COMMENTS, IF ANY:
MENTAL DISORDER DIAGNOSIS #3 ICD CODE:
COMMENTS, IF ANY:
ICD CODE:
Note - The Veteran is applying to the U.S. Department of Veterans Affairs (VA) for disability benefits. VA will consider the information you provide on this questionnaire as part
of their evaluation in processing the Veteran's claim. VA may obtain additional medical information, including an examination, if necessary, to complete VA's review of the
veteran's application. VA reserves the right to confirm the authenticity of ALL questionnaires completed by providers. It is intended that this questionnaire will be completed
by the Veteran's provider. This evaluation should be based on DSM-5 diagnostic criteria.
IMPORTANT - THE DEPARTMENT OF VETERANS AFFAIRS (VA) WILL NOT PAY OR REIMBURSE ANY EXPENSES OR COST INCURRED IN THE PROCESS OF
COMPLETING AND/OR SUBMITTING THIS FORM.
Are you completing this Disability Benefits Questionnaire at the request of:
Veteran/Claimant
Other: please describe
Are you a VA Healthcare provider?
Is the Veteran regularly seen as a patient in your clinic?
Yes No
Yes No
Was the Veteran examined in person?
Yes No
If no, how was the examination conducted?
NOTE: If the Veteran experiences a mental health emergency during the interview, please terminate the interview and obtain help, using local resources as appropriate.
You may also contact the Veterans Crisis Line at 1-800-273-TALK (8255). Stay on the Crisis Line until help can link the Veteran to emergency care.
