Records for VA Mental Health Claims

‍What is the VA Looking For in My Records?

Understanding what records to gather is one of the most important steps in building a strong VA mental health disability claim. The specific evidence you need depends on your situation, but having the right documentation can make the difference between approval and denial.

‍The VA needs to establish three key elements for any mental health disability claim:

1. Current Diagnosis - Do you have a diagnosable mental health condition right now?
2. Service Connection/Nexus - Is there a link between your condition and your military service or another service-connected disability?
3. Severity/Rating - How severe is your condition and how does it impact your daily functioning?

Different types of evidence serve different purposes in proving these elements. Some records help establish when symptoms first appeared, others show the progression of your condition, and some demonstrate the impact on your life and functioning.

‍

What Records Would Support My VA Disability Claim?

Military/VA Records

• DD-214
• Rating Decision Letter(s)
• Previous C&P Exam DBQ(s)
• Service Treatment Records (STRs)
• Reports of Medical History (RMHs)
• Pre/Post Deployment Health Assessments (PDHAs)
• Personnel Records, including performance ratings, disciplinary actions, awards
• VAMC Medical Records

Civilian Records

• Civilian Medical Records from before, during, or after service
• Employment records showing job performance issues
• School records if you attended school after service
• Records of relationship problems or divorce
• Documentation of legal issues that may be related to your mental health

Buddy Statements / Lay Statements

Written statements from people who knew you before, during, and after service can provide powerful evidence about:

• Your mental health before military service
• Changes they observed during your service
• How your condition has affected you since service
• Specific incidents or stressors you experienced

‍

What Evidence Should I Look for in My Records?

When you start gathering your records, it helps to know what types of evidence would be helpful and where you might find it.

Some evidence is pretty straightforward, such as:

• Mental health diagnoses
• Psychiatric medications prescribed
• Counseling or therapy sessions
• Mental health-related doctor visits or ER visits
• Psychological testing or evaluations

Those will usually be found in your STRs, RMHs, or civilian medical records.

Other evidence requires a deeper understanding of mental health AND a more thorough search.

This is a common reason for a claim to be denied when it should have been service-connected. Many C&P examiners are overlooking and/or misinterpreting evidence that would support your claim.

The good news? I've spent years mastering the art of finding evidence others miss. While I can give you some guidelines to start with, properly identifying and interpreting this evidence requires specialized knowledge of both mental health disorders and VA Disability Claims - which is exactly what I bring to your case.

That said, here are some starting points to help you begin identifying these often-overlooked signs in your records:

• Sleep problems - Insomnia, nightmares, sleep disturbances
• Physical symptoms - Unexplained fatigue, weight changes, gastrointestinal issues
• Behavioral changes - Disciplinary actions, performance issues, attitude changes
• Substance use - Alcohol or drug-related incidents
• Relationship problems - Marital issues, social isolation
• Stress-related symptoms - Anxiety, panic attacks, difficulty concentrating

While these types of evidence might also be found in your STRs, RMHs, or civilian medical records, I encourage you to look beyond the medical records. These can be mentioned in performance evaluations, PT tests, and various personnel records.

Find out what records you need for your Fieldstone Service Plan.

‍

‍