How to Document Mental Health for a Disability Application

Robin Mead

Tips and ideas for documenting mental health in your Social Security disability application.

Choosing a Doctor

🌟 Social Security has specific rules about what type of doctor they would like you to see. If you have been diagnosed with mental illness, Social Security will give the most consideration to records from a psychiatrist or licensed psychologist. They will give less consideration to records from a therapist, counselor, or Social Worker (those records can still help, though). These rules are called “acceptable medical source rules”

🌟 You can also have more than one mental health practitioner. For example, you can have both a therapist and a psychiatrist. As long as their records both agree about your level of disability and say similar things, this can be a great combo! (If they disagree about whether you are disabled, this may cause problems).

Doctor’s Forms and Letters

🌟 A function form or medical opinion letter from your psychologist, psychiatrist or other doctors can be a huge help to your case. Social Security will not ask your doctor for this, so you will need to ask yourself:

🌟 Here’s where you can find sample forms along with tips for working with your doctor: Sample Disability Letters and Sample Function Forms

Following Treatment

🌟 If possible, it is a great help to have regular visits with a psychiatrist or psychologist, and to follow all of her treatment recommendations. If you are unable to follow your doctor’s recommendations there are some exceptions to this rule. See: How to Please the Social Security Gods

🌟 If you can’t take psych meds, some readers report they had better experiences with finding a psychologist than a psychiatrist.

Be Embarrassing!

🌟 Some people (unintentionally) sabotage their applications because they are shy or embarrassed about admitting all their mental health symptoms. Being honest and upfront about all your symptoms at every visit How to Have Doctor Visits That Create Accurate Records

🌟 Ivy was denied disability for two years. She reapplied and got approved in just six weeks! One of the big changes she made was being more upfront about her mental health symptoms: Ivy Applies Again

Clinical Observations

🌟 When you are at the doctor, your doctor may make notes about how you dress, move, talk, act, and respond. These notes are called “clinical observations” and can be very important in your disability case. Acacia was kind enough to share her story: Acacia Gets Approved Through Clinical Observations

🌟 These types of clinical observations can be made by ALL doctors, not just mental health doctors. Some primary care doctors routinely write a small “mental status report” in every record. Learn more about: What is My Doctor Writing About Me?

Lyme, ME, CFS, POTS, and Environmental Illness

🌟 Many people with Lyme, ME, Multiple Chemical Sensitivities, and related conditions hate being labeled as mentally ill. They resist and resent including mental health with their disability claim. BIG MISTAKE. Mental health is often the key to approval for people with invisible illnesses.

🌟 On the other hand, if you are applying for LTD (private disability through your employer), mental health documentation can sometimes cause problems How to Include Mental Health. Or How to Leave Out Mental Health.

Psychiatric Testing

🌟 Psychiatric testing is not required, and many people are approved without testing, and based on their ongoing records from psychologists, psychiatrists, or psychiatric hospitalizations.

🌟 Although it is not required, testing can certainly be helpful. If possible, ask your doctor if she can perform any psychiatric or psychological assessments on you to further document your condition, or if they can refer you to someone who can. If you have a lawyer who is local, ask your lawyer if she can recommend someone in your area who can do this. Some lawyers also give free consultations where you can ask this question.

🌟 You can also ask local lawyers if they know any doctors who offer psychiatric testing i . your area. Lawyers often are aware which doctors are most detailed and accurate in their reports. Many lawyers give an initial consultation for free. Links to Lawyers

🌟 Also try Google! Type in: “Your town” + “forensic” + “psychiatrist.” Or type in: “Your state” + “forensic” + “psychiatrist.” If possible, try to look for doctors who are interested in working directly for patients. Some doctors work as “independent medical examiners” primarily hired by large insurance companies and corporations seeking to deny workers comp and disability benefits.

Neuropsychological Testing

🌟 This is different than psychiatric testing. This is special testing to test your memory, focus and concentration. It may be called neurocognitive or neuropscyhiatric or neuropsychological testing.

🌟 Many people find that this kind of testing is a great help to their disability application. Learn more about how to get neurocognitive testing.

🌟 Here’s some tips for: How to Find a Good Neuropsychologist

🌟 Sample reports from patients with fibromyalgia and ME/CFS Read Sample Neuropsychological Reports

🌟 Warning: If you are applying for LTD or private disability through your employer please read this page. This does not apply to Social Security Disability. How Neuropsychological Testing Can Help (or hurt) Your Long Term Disability Application

Finding Doctors for Mental Health Testing

Real life story: Pansy called three local disability lawyers and asked them for a free consultation. She asked each of them for recommendations for a doctor for testing plus an ongoing doctor for treatment. Two lawyers offered no information. The third one gave her a detailed run down of all the local doctors and what their strengths were. Pansy found a great doctor and a great lawyer! Links to Lawyers

Reading Your Records

🌟 It is very very helpful if you can read your doctor’s treatment notes and see what they are writing about you. Many mental health practices will automatically say “no” when you request your records and treatment notes. Don’t give up: How to Get Psych Records

Talking to Your Doctor

🌟 It is really important and really helpful to talk to your doctor about your disability application.

🌟 If your doctor is supportive but hates paperwork, check out: How To Get Your Doctor to Fill Out Disability Paperwork

Unsupportive Doctors

🌟 Some mental health doctors do not support any of their patients to apply for disability. These doctors often state that they believe “working is good for your health” or “recovery is possible” and going on disability is not good for mental health. Unfortunately, some of our readers have become homeless because of doctors with this belief system.

🌟 Dandelion had an unsupportive doctor. Here’s what she did: Dandelion’s Psychologist Does Not Support Her Disability Application

Getting Help

🌟 If you have a Caseworker, Social Worker, Counselor or Therapist, please take a look here for special tools and forms you can print and bring to your worker: How to Get a Social Worker to Help with Your Disability Application

🌟 The SOAR program provides help to people who are homeless (or at risk) and have a mental illness diagnosis. They can be a huge help with disability applications and they have helped many people get approved remarkably quickly. This program is free: How To Get Help from The Amazing SOAR Program

🌟 If SOAR is not available in your area, you could try to work with a local Caseworker or Social Worker to create a report that has similar elements to a SOAR report: How to Create a Medical Summary Report and and How to Get a Social Worker

🌟 Disability lawyers and advocates can help you prepare your case and do not charge anything unless you win. How To Find a Good Lawyer or How to Apply Without a Lawyer

🌟 Many of our readers report getting their best help from friends or family members. Jamesia helped her friend apply and her friend was approved in just two months! She has lots of great and helpful advice you can use yourself or with a friend: How to Help a Friend Get Approved for Disability

🌟 Peggy helped her adult son get approved in just three months: Peggy Gets Approved Using a Medical Summary Report

🌟 Many of our readers with mental illness ask if they are eligible for the same services and accommodations as someone physical disabilities. The answer is usually: yes. Learn more about other kinds of help: Mental Health Qualifies!

Using The Blue Book

🌟 If you have been diagnosed with serious mental illness, you may be able to get approved by using the Social Security Blue Book. This is not that simple to do, but if it works, you can get approved automatically! How to Use the Blue Book

🌟 Jamesia used the Blue Book to help her friend get approved based on her mental health impairments. Here’s how they did it: Jamesia and Magnolia Use the Social Security Blue Book

“Do I Need to Go To a Psych Hospital?”

No. Some people think that the only people who get approved are people who have been in psychiatric hospitals. Not true. Many people are approved for mental health who have never stayed in a hospital.

“I Can’t See a Psychiatrist or Psychologist”

If a psychiatrist or psychologist is not possible for you, then you can instead try a combination: A counselor/therapist plus a doctor who treats your mental health.

The doctor can be your regular doctor. Please check to make sure your doctor is an MD or another kind of “acceptable medical source.” Your doctor would need to be treating mental health and including information about mental health in your ongoing records. Both your doctor and your counselor can complete the mental RFC.

“I Am Applying for LTD. Can I Get Approved for Mental Health?”

Long Term Disability is disability insurance offered through your employer. If you are applying for mental health, you may run into a problem.

Many (nearly all) LTD policies have a cap on mental health claims. Learn more on this page: How to Avoid Getting Capped

If you are planning to get neuropsych testing please read more: How Neuropsychological Testing Can Help (or hurt) Your Long Term Disability Application

What Do You Think? 

Please comment below with stories, ideas, questions or suggestions. Please let us know if any links on this page stop working.

Updated May 2019. If you found this page helpful, please share it with others by pressing one of these magic little buttons: