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Mental health related disabilities are among the most commonly missed, undiagnosed or under rated disabilities for Veterans. Beyond costing Veterans hundreds, if not thousands, of dollars in missed disability compensation it costs on average 6,000 Veteran’s their lives per year in suicides that may have been able to be prevented with proper diagnosis, treatment and support. Undiagnosed and untreated mental health disabilities are also one of the leading reasons for homelessness in the Veteran community. The purpose of this form is to determine if you may qualify for service connection for any mental health related disabilities, or if you qualify for any increases for any currently service connected mental health disabilities, or if you qualify for any secondarily related mental health disabilities due to any currently service connected disabilities. Please take the time to read the questions carefully, be sure you understand what is being asked and answer as openly and honestly as possible. This could lead to more than just an increase in your disability rating, but to also getting the support you need by qualifying you for one of the many VA programs designed to treat and support Veterans and their families.

PHQ-9

Over the last 2 weeks, how often have you been bothered by any of the following problems? (Use “✔” to indicate your answer)	Not at all (0)	Several Days (1)	More than half the days (2)	Nearly every Day (3)
1. Little interest or pleasure in doing things This field is required
2. Feeling down, depressed, or hopeless This field is required
3. Trouble falling or staying asleep, or sleeping too much This field is required
4. Feeling tired or having little energy This field is required
5. Poor appetite or overeating This field is required
6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down This field is required
7. Trouble concentrating on things, such as reading the newspaper or watching television This field is required
8. Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual This field is required
9. Thoughts that you would be better off dead or of hurting yourself in some way This field is required
Score

If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
This field is required

Not difficult at all

Somewhat difficult

Very difficult

Extremely difficult

GAD-7

Over the last 2 weeks, how often have you been bothered by any of the following problems? (Use “✔” to indicate your answer)	Not at all (0)	Several Days (1)	More than half the days (2)	Nearly every Day (3)
1. Little interest or pleasure in doing things This field is required
2. Not being able to stop or control worrying This field is required
3. Worrying too much about different things This field is required
4. Trouble relaxing This field is required
5. Being so restless that it’s hard to sit still This field is required
6. Becoming easily annoyed or irritable This field is required
7. Feeling afraid as if something awful might happen This field is required
Score

If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
This field is required

Not difficult at all

Somewhat difficult

Very difficult

Extremely difficult

PTSD – PCL-5 Questionnaire

	Not at all (0)	A little bit (1)	Moderately (2)	Quite a bit (3)	Extremely (4)
1. Repeated, disturbing, and unwanted memories of the stressful experience This field is required
2. Repeated, disturbing dreams of the stressful experience This field is required
3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it) This field is required
4. Feeling very upset when something reminded you of the stressful experience This field is required
5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating) This field is required
6. Avoiding memories, thoughts, or feelings related to the stressful experience This field is required
7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations) This field is required
8. Trouble remembering important parts of the stressful experience This field is required
9. Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous) This field is required
10. Blaming yourself or someone else for the stressful experience or what happened after it This field is required
11. Having strong negative feelings such as fear, horror, anger, guilt, or shame This field is required
12. Loss of interest in activities that you used to enjoy This field is required
13. Feeling distant or cut off from other people This field is required
14. Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you) This field is required
15. Irritable behavior, angry outbursts, or acting aggressively This field is required
16. Taking too many risks or doing things that could cause you harm This field is required
17. Being superalert or watchful or on guard This field is required
18. Feeling jumpy or easily startled This field is required
19. Having difficulty concentrating This field is required
20. Trouble falling or staying asleep This field is required
Score

Unsure? We are here to help! Please email VBE at vbe@veteransbenefitsevaluations.com if you need assistance.

Active Orders

Before You Go!

Sign up for a FREE no-commitment, consultation to discuss your current disability claim, and find out if our medical experts can assist you in getting an additional increase in your disability.

Active Orders

Informed Consent – Medical Evaluation

PHQ-9

GAD-7

PTSD – PCL-5 Questionnaire

Informed Consent

Informed consent – Psych Evaluation

PHQ-9

GAD-7

PTSD – PCL-5 Questionnaire

Before You Go!

Sign up for a FREE no-commitment, consultation to discuss your current disability claim, and find out if our medical experts can assist you in getting an additional increase in your disability.