An evaluation by a qualified mental health professional is often crucial when a veteran is seeking VA disability compensation for post-traumatic stress disorder (PTSD).

These pointers may help you to prepare an effective report.

1. At the beginning of your report, it’s essential to give the VA a solid basis for judging the weight that your evaluation should carry: When did you first meet the veteran? How often have you seen him or her? One-on-one, or in group? At the VA? At another facility? In private practice?
   If you’ve seen the veteran in a particular program, describe the objectives of the program. If your expertise in PTSD is not apparent from your job title or organizational affiliation, please include enough of your C.V. to give the VA a sense of your qualifications.
2. If you have administered psychological tests to the veteran, please identify the tests, state when they were administered, and discuss the significance of the test results.
3. If you have reviewed records of the veteran’s prior treatment, please identify them.
4. Describe any currently-prescribed psychotropic medications and discuss their efficacy for the veteran. Is the veteran suffering from any side effects? Has it been necessary to change medications? To adjust dosages? If so, why? If the veteran has refused to take recommended medications, please discuss the reasons for his or her refusal.
5. Identify the stressful events that led to the development of PTSD, and describe them in some detail.
6. Specify when the onset of PTSD occurred. Identify the veteran’s symptoms within each of the DSM PTSD symptom clusters, and indicate their severity. If possible, cite specific instances of each symptom. Please be certain to state whether the veteran’s PTSD was caused by events in the military, as opposed to events in civilian life.
7. Discuss the impact of the veteran’s PTSD symptoms upon his or her relationships, performance in the workplace, judgment, thinking, and mood.
8. If the veteran has a history of substance abuse, please state clearly whether (and to what extent) the substance abuse is secondary to PTSD—i.e., self-medication to quell PTSD symptoms. If the veteran’s substance abuse has persisted, indicate the probable reason(s).
9. If the veteran has been diagnosed with other psychiatric conditions (e.g., depression, dysthymia) in addition to PTSD, please state clearly whether (and to what extent) the conditions are secondary to PTSD.
10. Please include a statement regarding the veteran’s prognosis. If the prognosis hinges upon whether the veteran remains in treatment, please explain.
11. A multi-axial assessment—and, in particular, an accurate GAF score on Axis V—is crucial to a thorough evaluation.

NOTE

The VA typically disregards evaluations more than one year old. If you prepared a full evaluation more than a year ago, it will need to be updated before it can be submitted to the VA.

Disclaimer
This memorandum provides general information only. It does not constitute legal advice, nor does it substitute for the advice of an expert representative or attorney who knows the particulars of your case. Any use you make of the information in this memorandum is at your own risk. We have made every effort to provide reliable, up-to-date information, but we do not guarantee its accuracy. The information in this memorandum is current as of December 2012.

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