Social Security Disability Psychological Evaluation Questionnaire
Complete this questionnaire to provide information for a psychological evaluation related to a Social Security disability claim.
Applicant Information
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preferred Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Referral and Evaluation Context
Referred by / Requested by
*
Referral or Request Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Evaluation / Claim Context
*
Treatment and Medication History
Mental Health Treatment History
*
Rows
Provider Type
Treatment Dates or Duration
Current/Past Status
Psychiatrist
Psychologist/Therapist
Counselor
Primary Care Provider
Other Provider
Current Psychiatric Medications
Any prior mental health hospitalizations or crisis visits?
*
Yes
No
If yes, briefly describe the hospitalization or crisis visit(s)
Daily Functioning and Work Impact
Impact on daily activities and work functioning
*
Rows
No difficulty
Mild difficulty
Moderate difficulty
Severe difficulty
Unable to do
Self-care
1
2
3
4
5
Household tasks
6
7
8
9
10
Remembering instructions
11
12
13
14
15
Interacting with others
16
17
18
19
20
Handling stress
21
22
23
24
25
Maintaining attendance
26
27
28
29
30
Completing tasks
31
32
33
34
35
Examples of functional limitations
Submit
Should be Empty: