Evidence Social Security Requires for Mental Disabilities

The Social Security Administration (SSA) looks at several sources of information when deciding on disability applications based on mental health conditions. Social Security sifts through your medical records for evidence of your mental health condition to see three things:

• whether you have a "medically determinable impairment" (a solid diagnosis based on objective evidence)
• whether your mental health condition is so severe that it prevents you from working, and
• whether your impairment has lasted or is expected to last at least a year.

Qualifying for Social Security disability insurance (SSDI) or Supplemental Security Income (SSI) disability benefits based on psychiatric or psychological impairments can be challenging. Here's what you need to submit to the SSA to prove you can't work because of a mental disability.

Social Security Disability Application Forms

The first source of evidence in your disability case is your application. You can complete the application yourself, or a Social Security representative might complete the forms for you during a phone or in-person interview. (Learn more about the forms used for filing for Social Security disability.)

When you fill out your application, make sure to list all of your conditions and all the ways they prevent you from working. In the end, it might be a combination of impairments that qualifies you for disability, even though you think only one impairment is keeping you from working. In fact, it's not uncommon for applicants to qualify for disability benefits based on multiple impairments.

Activities of Daily Living Questionnaire for Mental Disabilities

Social Security will have you complete a questionnaire about your "activities of daily living," or ADLs. Also known as the Function Report (Form SSA-3373), this questionnaire asks you to describe how your impairment limits your daily life. The form asks about a wide range of activities, including things like:

• spending time with others
• doing housework
• getting around outside the home
• using money, and
• shopping.

Be sure to describe all the problems your mental illness causes you, such as:

• trouble following instructions
• difficulty staying on task
• inability to complete projects
• difficulty getting along with coworkers or supervisors, or
• trouble handling stress.

Make sure your answers are as thorough and complete as possible. (Learn more about how to complete the ADL questionnaire for Social Security.)

Sharing Your Medical Records With Social Security

Social Security is required to look at all your relevant medical records for at least 12 months before the date of your application for benefits. When you complete the application, you'll list all of your treatment providers, like

• doctors
• counselors or psychologists
• clinics
• hospitals, and
• other treatment centers.

Social Security will ask you to sign an Authorization to Disclose Information (Form SSA-827) so the agency can get your records from your treatment providers, if you haven't already submitted them. While Social Security has an obligation to help you get all of your medical records, submitting them yourself will help you avoid delays in your case.

(Learn what you need from your doctor to prove you qualify for SSDI or SSI.)

Disability Evidence Should Include Psychiatric or Neurological Testing

Your medical records should contain the results of any psychiatric, neurological, or psychological tests you've had. Many mental health conditions can't be evaluated with an objective test, but some can. Where objective testing is possible, Social Security will look carefully at those results.

For example, if you're applying for disability benefits for borderline intellectual disorder or intellectual disorder (formerly known as mental retardation), you'll need to show the results of standardized intelligence testing (IQ tests).

Mental Disability Claims Often Hinge on Treatment Notes

Treatment notes from mental health professionals are usually the most crucial source of evidence in mental disability claims. But there can be lots of problems with treatment notes.

Providers often don't keep thorough notes. But Social Security needs to see the details of your mental health treatment, including things like:

• your diagnosis
• your symptoms
• your treatment plan
• your prognosis
• the history of your treatment, including every medication prescribed, and
• how you responded to every kind of treatment that the provider tried.

Ideally, treatment notes should also contain details about how your mental condition has impaired your functioning.

For example, if you claim that your anxiety disorder makes it impossible to work because you can't leave your house, your psychiatrist's notes should document your fear of leaving the house. The notes should also show that your anxiety persists despite medication and treatment.

(Learn more about what it takes to get disability for anxiety-related disorders.)

Social Security RFC Form for Mental Impairments

Even when treatment notes are thorough, they usually don't have much detail about how your mental condition affects your ability to function (specifically, how your impairment prevents you from doing work activites). Consider asking your doctor to complete a mental residual functional capacity (RFC) assessment (Form SSA-4734-F4-SUP).

Social Security will give substantial weight to your treating doctor's opinion about your condition and ability to function as long as:

• it's supported by medical evidence, and
• it's consistent with other evidence.

Having your doctor complete a full mental RFC form can be one of the most important things you can do for your case.

Your Therapy Notes Can Remain Private

Social Security won't use psychotherapy notes when evaluating your disability. Those notes are taken during counseling or therapy sessions and are based on your conversations with your doctor or therapist.

Therapy notes should remain private. Your doctor can simply not send the notes or black them out if they're in the middle of other relevant records.

Social Security Consultative Exams for Mental Disabilities

A claims examiner at your state's disability determination agency (DDS) will consider your evidence and decide on your application for benefits. The claims examiner will look at all the information you list about your impairments, plus your medical records, then do one of the following:

• approve your claim
• deny your claim, or
• decide that more information is needed.

If the claims examiner wants more information before deciding your claim, you'll likely be sent for a consultative exam (CE).

In mental disorder cases, Social Security might send you for a mental status exam, specific testing or to a psychiatrist for a thorough examination. Social Security generally prefers to arrange a CE with your own health care provider. But it's not unlikely that you'll be referred to another doctor for a mental CE, especially if your treating doctor isn't a psychiatrist.

(Learn more about the types of mental exams and what you can do to prepare for your mental exam.)

Other Sources of Evidence for a Mental Disability Claim

Social Security might contact third parties you've identified to ask them about your activities. Some of the people who know you well can offer valuable information about you that can support your case, such as:

• social workers
• former employers
• probation officers
• teachers
• friends, and
• family.

Think of people who've seen the effects of your mental condition on your ability to function. If you want Social Security to contact specific people who can support your application, make sure you let those people know. And be sure you talk with them about your symptoms and impairments, so they're up-to-date on how your condition affects your daily activities.

Learn more about the kinds of mental impairments that can qualify for SSDI and SSI benefits.