Mental Disorders (Other Than PTSD and Eating Disorders) Disability Benefits Questionnaire - Updated on 2025-10-14

Sep 21, 2026

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Mental Disorders (Other Than PTSD and Eating Disorders) Disability Benefits Questionnaire for U.S. Department of Veterans Affairs disability evaluation. Gathers patient/veteran identification, examination details, and applicant status, and instructs completion by qualified healthcare providers. Uses DSM-5 diagnostic criteria to document mental disorder diagnoses with ICD codes, relevant medical conditions including TBI, and symptom differentiation across multiple disorders. Includes questions on examination authorization, circumstances of emergency interruption, and requirements for initial vs review examinations.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages8

Reading Time20 min

AccessFree to download

Instructions and applicant context

Department of Veterans Affairs notice and evaluation purpose

Emergency guidance and examination authorization

Section 1 - Diagnosis

Current or past mental disorder diagnoses (A1)

Relevant medical diagnoses including TBI (A2)

Symptom differentiation and related TBI questions

Multiple diagnosed disorders and attribution (B1-B2)

Traumatic Brain Injury evidence and differentiation (B3-B4)

| | | | | | | MENTAL DISORDERS (OTHER THAN PTSD AND EATING DISORDERS) DISABILITY BENEFITS QUESTIONNAIRE | | | | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | Name of Patient/Veteran | | | | | | | | Patient/Veteran's Social Security Number | | | Date of Examination: | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | 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. | | | | | | | | | | | | | | | | 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 completed questionnaires. Please note that this questionnaire is for disability evaluation, not for treatment purposes. This evaluation should be based on DSM-5 diagnostic criteria. It is intended that this questionnaire will be completed by the Veteran's healthcare provider. | | | | | | | | | | | | | | | | Note: If the Veteran experiences a mental health emergency during the interview, please discontinue the interview and obtain help, using local resources as appropriate. You may also contact the Veterans Crisis Line by dialing 988 and pressing 1. Stay on the Crisis Line until the Veteran is linked to emergency care. | | | | | | | | | | | | | | | | Note: Initial Mental Disorders examinations must be conducted by (1) a board-certified or board-eligible psychiatrist; (2) a licensed doctorate-level psychologist; (3) anon-licensed doctorate-level psychologist working toward licensure under close supervision; (4) a psychiatry resident under close supervision; or (5) a VHA psychology trainee, under close supervision, who is completing an internship or residency for the purposes of completing a doctorate-level degree program.
Mental Disorders review examinations must be conducted by (1) an individual eligible to conduct an initial Mental Disorders examination; (2) a licensed clinical social worker (LCSW) under close supervision; or (3) a nurse practitioner, clinical nurse specialist, or physician assistant, if that individual is under close supervision and is clinically privileged by VHA to perform activities required for C&P Mental Disorders examinations.
“Under close supervision” means that the individual is supervised by a board-certified or board-eligible psychiatrist or licensed doctorate-level psychologist who must meet with the Veteran, confer with the supervised individual in providing the diagnosis and the final assessment, and co-sign the examination report. | | | | | | | | | | | | | | | | Are you completing this Disability Benefits Questionnaire at the request of: | | | | | | | | | | | | | | | |
Veteran/Claimant

Third party (please list name(s) of organization(s) or individual(s))

Other: please describe
| | | | | | | | | | | | | | | | Are you a VA Healthcare provider? Yes No
Is the Veteran regularly seen as a patient in your clinic? Yes No
Was the Veteran examined in person? Yes No | | | | | | | | | | | | | | | | If no, how was the examination conducted? | | | | | | | | | | | | | | | | SECTION 1-DIAGNOSIS | | | | | | | | | | | | | | | | A. Diagnosis
A1 . Does the Veteran now have or has he or she ever been diagnosed with a mental disorder(s)?
Yes No ICD Code:

NOTE: If the Veteran has a diagnosis of an eating disorder, complete the Eating Disorders Questionnaire, in lieu of this questio

FAQs

Who is instructed to complete this questionnaire?

It is intended for completion by the Veteran’s healthcare provider, with initial and review examinations requiring specific qualified examiner types under close supervision rules.

What diagnostic framework and codes does the questionnaire require?

The evaluation should be based on DSM-5 diagnostic criteria, and diagnoses must be recorded with ICD codes.

How does the questionnaire handle multiple mental disorders and TBI?

It asks whether multiple mental disorders were diagnosed and whether symptoms can be differentiated by diagnosis, and it specifically addresses evidence of Traumatic Brain Injury (TBI) and symptom attribution to TBI versus non-TBI mental health diagnoses.

Sep 21, 2026

Upload by Rhys