Essential Records Guide: What to Submit Based on Your Situation

Submitting the right records can strengthen a VA mental health disability claim. The records that matter most depend on your specific claim situation: whether you are filing a first claim, appealing a denial, seeking a higher rating, filing for Individual Unemployability, or proving a primary or secondary service connection. This guide helps you identify the essential records to gather and the additional documents that may help address common reasons for denial.

Find Records For Your Situation:

• Filing my first primary mental health claim
• Filing a secondary claim — already have a diagnosis
• Filing a secondary claim — do not have a diagnosis yet
• Increasing my VA mental health rating
• Filing for Individual Unemployability
• Denied for an undocumented pre-existing condition
• Denied for a documented pre-existing condition
• Denied due to personality disorder or congenital condition
• Denied for no diagnosis
• Proving connection for a primary claim
• Secondary claim denied as pre-existing
• Secondary claim denied for no diagnosis
• Proving connection for a secondary claim

Filing My First Primary Mental Health Claim

The Goal:

Provide evidence that you have mental health symptoms and that those symptoms began during service, were caused by something that happened during service, or are otherwise connected to your military service.

Essential Records to Gather‍

Start with these if you have them:

• DD-214 (Certificate of Release or Discharge)
• Service Treatment Records, especially any notes about sleep problems, anxiety, depression, panic, anger, concentration problems, substance use, or stress-related physical symptoms
• Report of Medical History, including enlistment, separation, deployment, or periodic health assessments, if available
• Current mental health treatment records, if you have already been evaluated or treated
• Personal statement explaining when symptoms began, what changed during or after service, and how symptoms affect your daily life

Additional Records That May Strengthen Your Claim

These can help show when symptoms started, how they progressed, or how they affected your functioning:

• Personnel records showing performance changes, disciplinary issues, transfer requests, or changes in behavior
• Deployment records, incident reports, or records related to stressful events
• Buddy statements from people who knew you before, during, or after service
• Civilian medical or counseling records from after service
• Employment records showing difficulty with attendance, reliability, concentration, irritability, or workplace relationships
• Records showing relationship problems, legal issues, substance use, or other life changes connected to mental health symptoms

Important note

You do not need to have a formal diagnosis before filing a VA mental health claim. The VA can provide a free C&P exam to determine whether you have a diagnosable mental disorder. The strongest records are the ones that help show when your symptoms began, how they changed over time, and how they affect your functioning now.

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Filing a Secondary Claim — Already Have a Diagnosis

‍The Goal:

‍Provide evidence that your diagnosed condition was caused or aggravated by an already service-connected disability.

For Fieldstone Mental Health services, this may involve either:

• a diagnosed mental disorder secondary to a service-connected physical condition, such as tinnitus, chronic pain, sleep apnea, or another medical condition; or
• another diagnosed condition secondary to a service-connected mental disorder, when the requested opinion is within Fieldstone’s scope.

‍Essential Records To Gather

Start with these if you have them:

• DD-214 (Certificate of Release or Discharge)
• Rating decision letter showing your service-connected primary disability
• Rating decision letter or claim documents for the secondary condition, if already filed
• Medical records documenting the diagnosed non-mental health condition
• C&P exam / DBQ for the primary condition, if available
• C&P exam / DBQ for the secondary condition, if available

‍Additional Records That May Strengthen Your Claim

These can help show the connection between the two conditions:

• Treatment records showing when the secondary condition began
• Records showing the severity and functional impact of the service-connected primary disability
• Medical records documenting worsening over time
• Provider notes discussing how the primary condition affects sleep, mood, anxiety, pain, activity level, concentration, or daily functioning
• Medication records or treatment history for either condition
• Personal statement explaining when the secondary symptoms began and how they relate to the service-connected disability
• Buddy statements from people who have observed changes in your symptoms, functioning, or daily life

Important note

For a secondary claim, the diagnosis alone is not enough. The evidence needs to support a medical connection between the service-connected disability and the claimed secondary condition. That connection may involve causation or aggravation, meaning the service-connected disability made the other condition worse.

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Filing a Secondary Claim — Do Not Have a Diagnosis Yet

The Goal:

‍Provide evidence that you may have a diagnosable mental disorder and that your symptoms may have been caused or aggravated by an already service-connected disability.

This situation is different from a secondary claim where you already have a diagnosis. Here, the first evidence question is whether your symptoms meet diagnostic criteria for a mental disorder. The second question is whether that disorder is medically connected to your service-connected disability.

‍Essential Records To Gather

Start with these if you have them:

• DD-214 (Certificate of Release or Discharge)
• Rating decision letter showing your service-connected primary disability
• Medical records for the service-connected condition
• Any mental health treatment records, even if they do not list a formal diagnosis
• Primary care records mentioning sleep problems, anxiety, depression, irritability, panic, concentration problems, fatigue, or stress
• Medication records, if you have been prescribed medication for mood, anxiety, sleep, or related symptoms
• Personal statement explaining what symptoms you are experiencing, when they began, and how they relate to your service-connected disability

Additional Records That May Strengthen Your Claim

These can help show symptom development, functional impact, and the possible relationship between conditions:

• Records showing chronic pain, tinnitus, sleep disruption, mobility limitations, medical complications, or other effects of the service-connected condition
• Treatment notes showing changes in mood, anxiety, sleep, activity level, relationships, or daily functioning after the primary condition began or worsened
• Buddy statements from people who have observed changes in your mood, behavior, sleep, relationships, or functioning
• Employment records showing attendance problems, reduced reliability, concentration issues, irritability, or difficulty interacting with others
• Records showing increased isolation, reduced activity, relationship strain, or other life changes after the service-connected condition worsened
• Any prior screening results, psychological testing, crisis records, or counseling notes

Important note

You do not need to perfectly identify your diagnosis before seeking an evaluation. The first step is determining whether your symptoms meet criteria for a mental disorder. If a diagnosis is confirmed, the next question is whether the evidence supports a medical connection between that diagnosis and your service-connected disability.

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Increasing My VA Mental Health Rating

The Goal:

‍Provide evidence that your current VA mental health rating does not accurately reflect the severity of your symptoms or the level of occupational and social impairment they cause.

For a rating increase, the key question is not just whether your symptoms have gotten worse. The question is whether your symptoms create a higher level of impairment under the VA’s mental health rating criteria.

‍Essential Records To Gather

Start with these if you have them:

• DD-214 (Certificate of Release or Discharge)
• Most recent VA rating decision letter
• Prior C&P exam / DBQ, if available
• Recent mental health treatment records
• Medication records for mental health symptoms, sleep, anxiety, depression, mood instability, or related concerns
• Personal statement describing how your symptoms affect work, relationships, judgment, mood, reliability, concentration, daily routines, and ability to function independently

Additional Records That May Strengthen Your Claim

These can help show that your current rating is too low:

• Treatment records showing worsening symptoms or persistent impairment
• Therapy or psychiatry notes documenting functional limitations
• Employment records showing missed work, reduced reliability, accommodations, write-ups, conflict, reduced productivity, or job loss
• FMLA paperwork, disability paperwork, or workplace accommodation records
• Buddy statements from family, friends, coworkers, or supervisors describing changes in functioning
• Records showing social withdrawal, relationship strain, anger/irritability, panic, impaired concentration, impaired judgment, or difficulty adapting to stress
• Crisis records, ER visits, hospitalizations, or safety-related documentation, if applicable

Important note

For VA mental health ratings, the rating is based on occupational and social impairment, not simply the number of symptoms you have. The most useful records are the ones that show how your symptoms affect your ability to work, maintain relationships, manage daily life, and function consistently over time.

For a deeper explanation of how VA mental health ratings work and which symptoms tend to affect rating levels, read: Should I File for a Mental Health Increase? An Examiner’s Guide to the VA Rating Formula →

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Filing for Individual Unemployability

The Goal:

‍Provide evidence that your service-connected condition prevents you from securing or maintaining substantially gainful employment.

For mental health IU claims, the key issue is not just symptom severity. The evidence needs to show how your symptoms interfere with work-related functioning, such as reliability, attendance, concentration, social interaction, stress tolerance, task completion, and ability to function consistently in a competitive workplace.

‍Essential Records To Gather

Start with these if you have them:

• DD-214 (Certificate of Release or Discharge)
• Most recent VA rating decision letter
• Prior C&P exam / DBQ, if available
• Recent mental health treatment records
• Employment history, including dates of employment, job duties, and reasons jobs ended
• Personal statement explaining how your service-connected condition affects your ability to work consistently

‍Additional Records That May Strengthen Your Claim

These can help show how your mental health symptoms affect employability:

• Employment records showing attendance problems, reduced productivity, write-ups, conflict, accommodations, or termination
• FMLA paperwork, disability paperwork, leave records, or workplace accommodation records
• Performance evaluations showing decline or difficulty meeting expectations
• Statements from former supervisors, coworkers, family members, or friends describing work-related limitations
• Records showing difficulty maintaining routines, completing tasks, interacting appropriately, adapting to stress, or leaving the house consistently
• Documentation of self-employment difficulties, reduced income, failed work attempts, or work only possible in a protected/sheltered environment
• Treatment records documenting symptoms that affect occupational functioning, such as panic, irritability, sleep impairment, concentration problems, avoidance, depression, or impaired stress tolerance

Important note

IU is about whether your service-connected disabilities prevent substantially gainful employment. The most helpful records are the ones that translate symptoms into work limitations: what happens with attendance, reliability, productivity, social interaction, stress, and consistency over time.

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Denied for an Undocumented Pre-Existing Condition

The Goal:

‍Provide evidence that the VA incorrectly treated your condition as pre-existing, or that the VA did not properly apply the presumption of soundness.

This situation usually means the VA is saying your mental disorder existed before service, even though it was not documented on your enlistment examination. In that situation, the key records are the ones that help show whether the condition truly existed before service and whether symptoms began or worsened during military service.

‍Essential Records To Gather

Start with these if you have them:

• DD-214 (Certificate of Release or Discharge)
• Most recent VA rating decision letter
• Prior C&P exam / DBQ, if available
• Report of Medical History / enlistment exam, if available
• Service Treatment Records, especially any notes about mental health symptoms, sleep, panic, anxiety, depression, substance use, stress reactions, or behavioral changes
• Personal statement explaining what your functioning was like before service, what changed during service, and what the VA got wrong

Additional Records That May Strengthen Your Claim

These can help address whether the condition truly pre-existed service or whether symptoms began/worsened during service:

• Pre-service medical or counseling records showing no history of the claimed condition
• School, employment, or medical records showing stable functioning before service
• Service records documenting first onset of symptoms
• Personnel records showing behavior changes, performance decline, disciplinary issues, or transfer requests
• Military incident reports related to symptoms, stressors, injuries, or traumatic events
• Post-service treatment records showing continued symptoms after discharge
• Buddy statements from people who knew you before service and can describe your pre-service functioning
• Buddy statements from people who observed symptom onset or worsening during or after service

Important note

If a condition was not recorded on your enlistment examination, the VA generally has to overcome the presumption that you were sound when you entered service. The most helpful records are the ones that clarify what was actually documented before service, what changed during service, and whether the VA’s reasoning matches the evidence.

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Denied for a Documented Pre-Existing Condition

The Goal:

Provide evidence that your mental health condition was aggravated by military service beyond its natural progression.

This situation usually means the VA agrees you have a mental disorder, but says it existed before service and was not made significantly worse by service. If the condition was documented during the enlistment process, the key issue becomes whether the evidence shows a meaningful worsening during or because of military service.

‍Essential Records To Gather

Start with these if you have them:

• DD-214 (Certificate of Release or Discharge)
• Most recent VA rating decision letter
• Prior C&P exam / DBQ, if available
• Report of Medical History / enlistment exam
• Pre-service medical or mental health records, especially records showing baseline severity before service
• Service Treatment Records, especially records showing symptom increases, treatment, sleep problems, anxiety, depression, panic, anger, substance use, or functional decline
• Personal statement explaining what your symptoms were like before service, what changed during service, and how your functioning changed after service

‍Additional Records That May Strengthen Your Claim

These can help show the difference between your pre-service baseline and your later level of impairment:

• Pre-service treatment records showing symptoms were mild, stable, resolved, or well-controlled before service
• School, work, or medical records showing pre-service functioning
• Service records documenting worsening symptoms, new symptoms, increased treatment needs, disciplinary issues, performance decline, or behavioral changes
• Military incident reports or records related to events that may have aggravated the condition
• Post-service treatment records showing continued worsening after discharge
• Buddy statements from people who knew you before service and can describe your baseline functioning
• Buddy statements from people who observed worsening during or after service

Important note

For this type of denial, the most helpful records are the ones that create a clear before-service / during-service / after-service comparison. The question is not just whether the condition existed before service. The question is whether military service made it worse beyond what would normally be expected.

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Denied Due to a Personality Disorder or Congenital Condition

The Goal:

Provide evidence that the diagnosis may be incorrect, or that you developed a separate service-connected mental disorder during or because of service.

This type of denial usually means the VA is treating the condition as non-compensable because it considers the diagnosis developmental or congenital in nature. The key records are the ones that help clarify whether the diagnosis is accurate, whether another mental health diagnosis better explains your symptoms, and whether symptoms began or worsened during military service.

‍Essential Records To Gather

Start with these if you have them:

• DD-214 (Certificate of Release or Discharge)
• Most recent VA rating decision letter
• Prior C&P exam / DBQ, if available
• Report of Medical History / enlistment exam, if available
• Service Treatment Records, especially records showing mental health symptoms, sleep problems, anxiety, depression, trauma symptoms, panic, anger, substance use, or functional decline
• Current mental health treatment records
• Personal statement explaining what symptoms you experienced, when they began, and why the VA’s diagnosis does not seem to fit your actual history

Additional Records That May Strengthen Your Claim

These can help challenge the diagnosis or support an alternative diagnosis:

• Psychological evaluations or psychiatric records identifying a different diagnosis, such as PTSD, depressive disorder, anxiety disorder, or another mental disorder
• Treatment records showing response to trauma-focused therapy, depression treatment, anxiety treatment, or psychiatric medication
• Service records documenting symptom onset, behavioral changes, performance decline, disciplinary issues, or traumatic events
• Pre-service records showing stable functioning before military service
• Buddy statements from people who knew you before service and during/after service
• Records showing symptoms that do not fit the VA’s personality disorder or congenital-condition explanation
• Records showing a distinct change after a service event, deployment, injury, trauma, or period of worsening stress

Important note

For this type of denial, the most useful evidence is not just “more records.” It is evidence that helps answer a diagnostic question: Was the VA’s diagnosis accurate, or is there another mental health condition that better explains what happened? If there is a separate diagnosable mental disorder connected to service, that may create a different path forward.

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Denied for No Diagnosis

The Goal:

‍Provide evidence that you have a diagnosable mental health condition, or that the prior exam did not adequately assess your symptoms.

This type of denial usually means the VA is saying the evidence does not show a current diagnosed mental disorder. That may happen because your symptoms did not meet full diagnostic criteria, or because the C&P exam did not fully capture what you are experiencing.

‍Essential Records To Gather

Start with these if you have them:

• DD-214 (Certificate of Release or Discharge)
• Most recent VA rating decision letter
• Prior C&P exam / DBQ, if available
• Current mental health treatment records, if you have them
• Primary care records mentioning sleep problems, anxiety, depression, panic, anger, irritability, concentration problems, fatigue, substance use, or stress
• Medication records for mood, anxiety, sleep, panic, or related symptoms
• Personal statement describing your symptoms, when they began, how often they happen, and how they affect your daily life

Additional Records That May Strengthen Your Claim

These can help show symptoms, diagnosis, impairment, or examiner error:

• Psychiatric evaluations or psychological testing
• Therapy or counseling records
• Crisis records, ER visits, hospitalization records, or safety-related documentation
• Records showing sleep disturbance, panic symptoms, depression, anxiety, trauma symptoms, irritability, isolation, or impaired concentration
• Employment records showing missed work, reduced reliability, conflict, concentration problems, or performance decline
• Buddy statements from people who have observed changes in mood, behavior, sleep, relationships, or functioning
• Screening results or symptom checklists, if available

Important note

A symptom is not the same thing as a diagnosis. For example, depressed mood, anxiety, panic, anger, poor sleep, and concentration problems can all be important symptoms, but the VA generally needs evidence of a diagnosable mental disorder before granting service connection. The most useful records are the ones that help show the full symptom pattern and how those symptoms affect functioning.

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Proving Connection for a Primary Claim

The Goal:

Provide evidence that your current mental health condition is connected to your military service.

This situation usually means the VA agrees you have a mental disorder, but denied service connection because it did not find enough evidence of a nexus — the link between your current condition and your service. The most useful records are the ones that show symptoms, events, behavioral changes, or other evidence that may have been missed or misunderstood.

‍Essential Records To Gather

Start with these if you have them:

• DD-214 (Certificate of Release or Discharge)
• Most recent VA rating decision letter
• Prior C&P exam / DBQ, if available
• Service Treatment Records
• Report of Medical History, including enlistment, separation, deployment, or periodic health assessments, if available
• Current mental health treatment records
• Personal statement explaining what happened in service, when symptoms began, and how symptoms have continued or changed over time

Additional Records That May Strengthen Your Claim

These can help show the connection between your military service and your current mental health condition:

• Service records documenting mental health symptoms, sleep problems, anxiety, depression, panic, anger, substance use, stress reactions, or physical symptoms related to stress
• Personnel records showing performance decline, disciplinary issues, attitude changes, transfer requests, or other behavioral changes
• Military incident reports, deployment records, accident reports, or other records connected to stressful or traumatic events
• Buddy statements from people who served with you or knew you during service
• Statements from family or friends who noticed changes during or after service
• Post-service treatment records showing continuity of symptoms
• Records showing symptoms that may have been overlooked, such as insomnia, irritability, withdrawal, concentration problems, substance use, or relationship problems

Important note

For non-PTSD mental health claims, the VA usually looks for evidence that symptoms began or worsened during service. PTSD claims can follow different evidence rules depending on the stressor type. The most helpful records are the ones that show either a documented in-service connection or a pattern of symptoms and changes that supports the connection.

For more about how PTSD evidence rules differ from other mental health claims, read: PTSD Claims →

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Secondary Claim Denied as Pre-Existing

The Goal:

Provide evidence that your service-connected disability caused or aggravated your mental health condition, even if the VA says the mental health condition existed first.

This situation usually means the VA agrees you have a mental disorder, but says it existed before the service-connected disability and was not made significantly worse by that disability. The key issue is whether the evidence shows aggravation: that your service-connected condition made the mental health condition worse beyond its expected course.

‍Essential Records To Gather

Start with these if you have them:

• DD-214 (Certificate of Release or Discharge)
• Most recent VA rating decision letter
• Rating decision letter showing the service-connected primary disability
• Prior C&P exam / DBQ for the mental health condition, if available
• Prior C&P exam / DBQ for the service-connected primary condition, if available
• Mental health treatment records
• Medical records for the service-connected disability
• Personal statement explaining when mental health symptoms began, what the baseline was before the service-connected condition worsened, and how the service-connected disability affected your mental health

Additional Records That May Strengthen Your Claim

These can help show the relationship between the service-connected condition and worsening mental health symptoms:

• Medical records showing worsening of the service-connected disability
• Mental health records showing worsening after the service-connected disability began or worsened
• Treatment notes discussing pain, tinnitus, sleep disruption, mobility limitations, medical stress, functional loss, or reduced quality of life
• Medication records showing increased treatment needs over time
• Records showing reduced activity, isolation, relationship strain, work problems, or loss of independence connected to the service-connected disability
• Buddy statements from people who observed changes in mood, anxiety, sleep, irritability, isolation, or functioning after the service-connected disability worsened
• Employment records showing decline connected to combined physical and mental health limitations

Important note

For this type of secondary denial, the question is not only which condition came first. The more important question may be whether the service-connected disability made the mental health condition worse. The most useful records are the ones that show a clear timeline of baseline functioning, worsening of the service-connected condition, and worsening mental health impairment.

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Secondary Claim Denied for No Diagnosis

The Goal:

Provide evidence that you have a diagnosable mental health condition and that the condition may be connected to your service-connected disability.

This type of denial usually means the VA is saying there is not enough evidence of a current diagnosed mental disorder. For a secondary claim, there are two evidence questions: whether you have a diagnosable mental disorder, and whether that disorder was caused or aggravated by your already service-connected disability.

‍Essential Records To Gather

Start with these if you have them:

• DD-214 (Certificate of Release or Discharge)
• Most recent VA rating decision letter
• Rating decision letter showing the service-connected primary disability
• Prior C&P exam / DBQ for the mental health condition, if available
• Prior C&P exam / DBQ for the service-connected primary condition, if available
• Any mental health treatment records, even if they do not list a formal diagnosis
• Primary care records mentioning sleep problems, anxiety, depression, panic, irritability, concentration problems, fatigue, substance use, or stress‍
• Personal statement explaining your symptoms, when they began, and how they relate to your service-connected disability

Additional Records That May Strengthen Your Claim

These can help show symptoms, diagnosis, and the possible connection between conditions:

• Psychiatric evaluations or psychological testing
• Therapy or counseling records
• Medication records for mood, anxiety, sleep, panic, or related symptoms
• Treatment notes showing how the service-connected disability affects pain, sleep, activity level, independence, mood, anxiety, or daily functioning
• Records showing worsening mental health symptoms after the service-connected disability began or worsened
• Employment records showing missed work, reduced reliability, concentration problems, irritability, or difficulty interacting with others
• Buddy statements from people who observed changes in mood, sleep, behavior, relationships, or functioning
• Crisis records, ER visits, hospitalization records, or safety-related documentation, if applicable

Important note

For this type of denial, the first issue is diagnosis. The VA generally needs evidence of a current diagnosable mental disorder before it can grant service connection. If a diagnosis is established, the next question is whether the evidence supports a medical connection between that mental disorder and your service-connected disability.

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Proving Connection for a Secondary Claim

The Goal:

Provide evidence that your mental health condition was caused or aggravated by an already service-connected disability.

This situation usually means the VA agrees you have a mental health diagnosis, but denied the claim because it did not find enough evidence of a secondary nexus. In other words, the VA did not see a clear enough medical connection between your service-connected disability and your mental health condition.

‍Essential Records To Gather

Start with these if you have them:

• DD-214 (Certificate of Release or Discharge)
• Most recent VA rating decision letter
• Rating decision letter showing the service-connected primary disability
• Prior C&P exam / DBQ for the mental health condition, if available
• Prior C&P exam / DBQ for the service-connected primary condition, if available
• Any mental health treatment records, even if they do not list a formal diagnosis
• Medical records for the service-connected disability
• Personal statement explaining when your mental health symptoms began, how the service-connected disability affected your life, and why you believe the conditions are connected

Additional Records That May Strengthen Your Claim

These can help show how the service-connected disability affected your mental health:

• Treatment records showing the timeline of both conditions
• Records showing worsening pain, tinnitus, sleep disruption, medical limitations, reduced mobility, or loss of independence
• Mental health records discussing how the service-connected disability affects mood, anxiety, sleep, irritability, activity level, relationships, or daily functioning
• Provider notes that mention emotional distress related to the service-connected disability
• Medication records for both conditions
• Employment records showing functional decline related to the combined effects of physical and mental health symptoms
• Buddy statements from people who observed changes in your mood, anxiety, sleep, relationships, activity level, or functioning after the service-connected disability began or worsened
• Records showing reduced quality of life, social withdrawal, loss of activities, or increased dependence on others

Important note

For a secondary claim, the evidence needs to support more than the fact that two conditions exist at the same time. The strongest records help show a timeline and a medically reasonable connection between the service-connected disability and the mental health condition. That connection may involve causation or aggravation.

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How to Prioritize Your Records

You do not need to upload every record you have. In many cases, the strongest record packet is not the largest packet — it is the clearest one.

Start with the essentials for your situation, then add records that directly address the evidence problem in your claim. That may mean records showing diagnosis, service connection, aggravation, symptom severity, occupational impairment, or the relationship between a service-connected disability and a secondary condition.

For Fieldstone Records Reviews, the base fee covers forensic analysis of up to 50 pages of records. Files over 50 pages are reviewed in 50-page increments, with an additional fee for each increment.

When choosing what to include, prioritize records that help answer the main question for your claim path:

• What did the VA miss?
• What evidence supports the diagnosis, nexus, aggravation, or rating level?
• What records best show the timeline and functional impact?

If you are not sure where to start, use your Fieldstone Navigator result as your guide. Your result identifies the claim problem we are trying to solve, and this Records Guide helps you gather the records most likely to matter for that path.

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