Veterans Mental Health Disability Evaluation Questionnaire
Use this form to share veteran background, current mental health concerns, symptom impact, treatment status, and follow-up preferences for an evaluation review.
Veteran Background
Service Branch
*
Army
Navy
Air Force
Marine Corps
Space Force
Coast Guard
Other
Years of Service
*
Preferred Contact Method for Follow-up
*
Phone
Email
Text Message
Mail
Other
Mental Health Evaluation
Current mental health concerns
*
Anxiety
Depression
PTSD symptoms
Sleep problems
Anger or irritability
Substance use concerns
Other
Overall symptom severity
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Duration of current symptoms
*
Less than 1 month
1–6 months
6–12 months
More than 1 year
Intermittent/episodic
Not sure
Other
How these symptoms affect daily functioning
*
Currently receiving treatment or support
*
Yes, currently in treatment
Yes, receiving informal support only
No, not currently
Prefer not to say
Other
Support and Follow-up
Preferred next step for follow-up
*
Phone call
Telehealth
In-person
No follow-up at this time
Additional notes or details for the evaluator
Submit Questionnaire
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