VA Form 21-0960P-2 Mental Disorders (other than PTSD and Eating Disorders)

OMB Approved No. 2900-XXXX
Respondent Burden: 30 minutes

MENTAL DISORDERS (OTHER THAN PTSD AND EATING DISORDERS)
DISABILITY BENEFITS QUESTIONNAIRE
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. PLEASE READ THE PRIVACY ACT AND RESPONDENT BURDEN INFORMATION
ON REVERSE BEFORE COMPLETING FORM.
NAME OF PATIENT/VETERAN

PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

NOTE TO PHYSICIAN - Your patient 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.
Important - 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 VA Suicide Prevention Hotline at 1-800-273-TALK. Stay on the Hotline until help can link the
veteran to emergency care.
NOTE - In order to conduct an 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 doctoratelevel psychologist.
SECTION I - DIAGNOSIS
1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH A MENTAL DISORDER(S)?
YES

NO

(If "No," provide rationale in Item 1B)

NOTE: If the veteran has a diagnosis of an eating disorder, complete VA Form 21-0960P-1, Eating Disorder Disability Benefits Questionnaire in lieu of this
questionnaire. Also, if the veteran has a diagnosis of PTSD, the VA Form 21-0960P-4, Initial PTSD Disability Benefits Questionnaire must be completed by VHA staff
or a contract examiner in lieu of this questionnaire.
(If the veteran has more than one mental health diagnosis, provide all diagnoses:
DIAGNOSIS #1
DATE OF DIAGNOSIS:
ICD CODE:
NAME OF DIAGNOSING FACILITY OR CLINICIAN:
DIAGNOSIS #2
DATE OF DIAGNOSIS:
ICD CODE:
NAME OF DIAGNOSING FACILITY OR CLINICIAN:
DIAGNOSIS #3
DATE OF DIAGNOSIS:
ICD CODE:
NAME OF DIAGNOSING FACILITY OR CLINICIAN:
ADDITIONAL DIAGNOSIS (List using the above format)
DATE OF DIAGNOSIS:
ICD CODE:
NAME OF DIAGNOSING FACILITY OR CLINICIAN:
ADDITIONAL DIAGNOSIS (List using the above format)
DATE OF DIAGNOSIS:
ICD CODE:
NAME OF DIAGNOSING FACILITY OR CLINICIAN:
1B. PROVIDE RATIONALE (e.g., veteran does not currently have any diagnosed eating disorders):

VA FORM
DEC 2010

21-0960P-2

Page 1

SECTION II - SYMPTOMS
2. SYMPTOMS - For each level shown, check all symptoms that apply. Consider the cumulative impact of all diagnoses mental disorders that the examiner
judges related to military service, without attempting to differentiate which symptoms are specifically caused by which mental disorder.
A. Level I Has the veteran been diagnosed with a mental disorder, but symptoms are not severe enough either to interfere with occupational and social functioning or to require
continuous medication?
YES

NO

B. Level II Does the veteran have occupational and social impairment due to mild or transient symptoms, which decrease work efficiency and ability to perform occupational tasks only
during periods of significant stress, or are the veteran's symptoms controlled by continuous medication?
YES

NO

C. Level III Does the veteran have any symptoms from the list below?
YES

NO (If "Yes," check all that apply)
Depressed mood
Anxiety
Suspiciousness
Panic attacks that occur weekly or less often
Chronic sleep impairment
Mild memory loss, such as forgetting names, directions or recent events

D. Level IV Does the veteran have any symptoms from the list below?
YES

NO (If "Yes," check all that apply)
Flattened affect
Circumstantial, circumlocutory or stereotyped speech
Panic attacks more than once a week
Difficulty in understanding complex commands
Impairment of short and long term memory, for example, retention of only highly learned material, while forgetting to complete tasks
Impaired judgment
Impaired abstract thinking
Disturbances of motivation and mood
Difficulty in establishing and maintaining effective work and social relationships

E. Level V Does the veteran have any symptoms from the list below?
YES

NO (If "Yes," check all that apply)
Suicidal ideation
Obsessional rituals which interfere with routine activities
Speech intermittently illogical, obscure, or irrelevant
Near-continuous panic or depression affecting the ability to function independently, appropriately and effectively
Impaired impulse control, such as unprovoked irritability with periods of violence
Spatial disorientation
Neglect of personal appearance and hygiene
Difficulty adapting to stressful circumstances, including work or a worklike setting
Inability to establish and maintain effective relationships

F. Level VI Does the veteran have any symptoms from the list below?
YES

NO (If "Yes," check all that apply)
Gross impairment in thought processes or communication
Persistent delusions or hallucinations
Grossly inappropriate behavior
Persistent danger of hurting self or others
Intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene
Disorientation to time or place
Memory loss for names of close relatives, own occupation, or own name

VA FORM 21-0960P-2, DEC 2010

Page 2

SECTION III - OTHER SYMPTOMS
3. DOES THE VETERAN HAVE ANY OTHER SYMPTOMS ATTRIBUTABLE TO A MENTAL DISORDER THAT ARE NOT LISTED ON PAGE 2?
YES

NO

(If "Yes," describe):

SECTION IV - OCCUPATIONAL AND SOCIAL IMPAIRMENT
4. WHICH OF THE FOLLOWING BEST REPRESENTS THE VETERAN'S LEVEL OF OCCUPATIONAL AND SOCIAL IMPAIRMENT? (Check only one)
A mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupation and
social functioning or to require continuous medication
Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform
occupational tasks only during periods of significant stress, or; symptoms controlled by medication
Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks,
although generally functioning satisfactorily, with normal routine behavior, self-care and conversation
Occupational and social impairment with reduced reliability and productivity
Occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood
Total occupational and social impairment

SECTION V - CURRENT GLOBAL ASSESSMENT OF FUNCTIONING (GAF) SCORE
5. PROVIDE THE CURRENT GLOBAL ASSESSMENT OF FUNCTIONING (GAF) SCORE?

SECTION VI - COMPETENCY
6. IS THE VETERAN CAPABLE OF MANAGING HIS OR HER FINANCIAL AFFAIRS?
YES

NO

(If "No," explain)

SECTION VII - FUNCTIONAL IMPACT AND REMARKS
7. DOES THE VETERAN'S MENTAL DISORDER(S) IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

(If "Yes," describe impact, providing one or more examples)

8. REMARKS (If any)

SECTION VIII - PSYCHIATRIST/PSYCHOLOGIST/EXAMINER CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
9A. PSYCHIATRIST/PSYCHOLOGIST/EXAMINER SIGNATURE & TITLE

9B. PSYCHIATRIST/PSYCHOLOGIST/EXAMINER PRINTED NAME

9C. DATE SIGNED

9D. PSYCHIATRIST/PSYCHOLOGIST/EXAMINER PHONE NUMBER

9E. PSYCHIATRIST/PSYCHOLOGIST/EXAMINER MEDICAL LICENSE NUMBER

9F. PSYCHIATRIST/PSYCHOLOGIST/EXAMINER/ ADDRESS

NOTE - VA may request additional medical information, including additional examinations, if necessary to complete VA's review of the veteran's application.

IMPORTANT - Psychiatrist/psychologist please fax the completed form to

(VA Regional Office FAX No.)

NOTE - A list of VA Regional Office FAX Numbers can be found at www.vba.va.gov/disabilityexams or obtained by calling 1-800-827-1000.
PRIVACY ACT NOTICE: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of Federal Regulations
1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the United States, litigation in which the
United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel administration) as identified in the VA system of
records, 58/VA21/22/28, Compensation, Pension, Education and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is required to obtain
or retain benefits. VA uses your SSN to identify your claim file. Providing your SSN will help ensure that your records are properly associated with your claim file. Giving us your SSN account information is
voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is
required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect. The requested information is considered relevant and necessary to determine maximum benefits under the law. The
responses you submit are considered confidential (38 U.S.C. 5701). Information submitted is subject to verification through computer matching programs with other agencies.
RESPONDENT BURDEN: We need this information to determine entitlement to benefits (38 U.S.C. 501). Title 38, United States Code, allows us to ask for this information. We estimate that you will need
an average of 30 minutes to review the instructions, find the information, and complete the form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed.
You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain.
If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.

VA FORM 21-0960P-2, DEC 2010

Page 3