MENTAL RESIDUAL FUNCTIONAL CAPACITY QUESTIONNAIRE

Medical Source Statement for Social Security Disability

PATIENT INFORMATION

Patient Name: _________________________________________________
Date of Birth: _________________
Social Security Number: _____ - _____ - _________

PROVIDER INFORMATION

Provider Name: _________________________________________________
Credentials: ☐ MD ☐ DO ☐ PhD ☐ PsyD ☐ LCSW ☐ LPC ☐ LMFT ☐ Other: _________
Specialty: _________________________________________________
Practice Name: _________________________________________________
Address: _________________________________________________
Phone: _________________ Fax: _________________
Email: _________________________________________________
License Number: _________________ State: _________
NPI Number: _________________

TREATMENT RELATIONSHIP

1. Date of first evaluation/treatment: _________________

2. Date of most recent evaluation/treatment: _________________

3. Frequency of contact:
☐ Weekly or more ☐ Bi-weekly ☐ Monthly ☐ Quarterly ☐ Other: _________________

4. Total number of visits: _________

5. Type of treatment provided:
☐ Medication management
☐ Individual psychotherapy
☐ Group therapy
☐ Psychological testing
☐ Inpatient hospitalization
☐ Intensive outpatient program
☐ Partial hospitalization
☐ Other: _________________________________________________

DIAGNOSES

DSM-5 Diagnoses:

Primary psychiatric diagnosis: _________________________________________________

Comorbid substance use disorder? ☐ Yes ☐ No ☐ In remission
If yes, specify: _________________________________________________

CLINICAL FINDINGS

Describe the clinical findings, mental status examination results, and/or psychological testing that support your assessment:

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

GAF Score (if used): _____ Date: _________________
Note: SSA no longer requires GAF scores but may consider them as part of the record

Psychological Testing Administered:
☐ None
☐ MMPI-2/MMPI-3
☐ WAIS-IV
☐ Beck Depression Inventory (Score: _____)
☐ PHQ-9 (Score: _____)
☐ GAD-7 (Score: _____)
☐ PCL-5 (Score: _____)
☐ Other: _________________________________________________

SIGNS AND SYMPTOMS

Check all signs and symptoms currently present:

Mood/Affect:

☐ Depressed mood
☐ Anhedonia (loss of interest/pleasure)
☐ Elevated/expansive mood
☐ Irritability
☐ Mood swings
☐ Flat/blunted affect
☐ Inappropriate affect
☐ Labile affect

Anxiety:

☐ Generalized anxiety
☐ Panic attacks - Frequency: _________/month
☐ Obsessions
☐ Compulsions
☐ Social anxiety
☐ Specific phobias
☐ Agoraphobia
☐ Hypervigilance

Cognitive:

☐ Difficulty concentrating
☐ Memory impairment (short-term)
☐ Memory impairment (long-term)
☐ Disorientation
☐ Racing thoughts
☐ Confusion
☐ Slowed thinking

Thought Process/Content:

☐ Paranoia
☐ Delusions
☐ Hallucinations (auditory)
☐ Hallucinations (visual)
☐ Loose associations
☐ Tangentiality
☐ Ideas of reference

Behavioral:

☐ Social withdrawal/isolation
☐ Decreased energy/fatigue
☐ Sleep disturbance - Type: _________________
☐ Appetite disturbance
☐ Weight change
☐ Psychomotor agitation
☐ Psychomotor retardation
☐ Crying spells
☐ Self-harm behaviors
☐ Suicidal ideation
☐ Homicidal ideation
☐ Impulsivity
☐ Aggression

PTSD-Specific (if applicable):

☐ Intrusive memories/flashbacks
☐ Nightmares
☐ Avoidance behaviors
☐ Emotional numbing
☐ Exaggerated startle response
☐ Dissociative episodes

Other Symptoms:

_____________________________________________________________________________

MEDICATIONS

Medication Side Effects Affecting Function:
☐ Drowsiness/sedation
☐ Cognitive dulling
☐ Tremor
☐ Weight gain
☐ Dizziness
☐ Nausea
☐ Other: _________________________________________________

Has medication been optimized? ☐ Yes ☐ No ☐ Ongoing adjustment

Medication compliance: ☐ Good ☐ Fair ☐ Poor

HOSPITALIZATION HISTORY

Number of psychiatric hospitalizations: _________
Most recent hospitalization: _________________

PARAGRAPH B CRITERIA ASSESSMENT

(Per 20 C.F.R. Part 404, Subpart P, Appendix 1, Section 12.00)

Rate your patient's degree of limitation in each area:

1. UNDERSTAND, REMEMBER, OR APPLY INFORMATION

Ability to learn, recall, and use information to perform work activities

☐ None
☐ Mild - Slight limitation, can generally function well
☐ Moderate - Fair ability, noticeable limitation
☐ Marked - Serious limitation, very limited ability
☐ Extreme - No useful ability to function

Examples: Following instructions, learning new tasks, applying information, using judgment

Supporting clinical observations:
_____________________________________________________________________________
_____________________________________________________________________________

2. INTERACT WITH OTHERS

Ability to relate to and work with supervisors, co-workers, and the public

☐ None
☐ Mild
☐ Moderate
☐ Marked
☐ Extreme

Examples: Cooperating with others, handling conflicts, responding to criticism, maintaining socially appropriate behavior

Supporting clinical observations:
_____________________________________________________________________________
_____________________________________________________________________________

3. CONCENTRATE, PERSIST, OR MAINTAIN PACE

Ability to focus attention and stay on task at a sustained rate

☐ None
☐ Mild
☐ Moderate
☐ Marked
☐ Extreme

Examples: Completing tasks in timely manner, maintaining regular attendance, working alongside others without distraction, sustaining ordinary routine

Supporting clinical observations:
_____________________________________________________________________________
_____________________________________________________________________________

4. ADAPT OR MANAGE ONESELF

Ability to regulate emotions, control behavior, and adapt to changes

☐ None
☐ Mild
☐ Moderate
☐ Marked
☐ Extreme

Examples: Responding to demands, managing psychologically-based symptoms, adapting to changes, maintaining hygiene, setting realistic goals

Supporting clinical observations:
_____________________________________________________________________________
_____________________________________________________________________________

DETAILED MENTAL FUNCTIONAL CAPACITIES

Rate your patient's ability to perform each activity on a sustained basis in a competitive work environment

Rating Scale:
- Unlimited/Very Good - Able to function in this area with no limitations
- Good - Limited but satisfactory ability
- Fair - Ability seriously limited but not precluded
- Poor - No useful ability to function
- None - Total lack of ability

A. UNDERSTANDING AND MEMORY

B. SUSTAINED CONCENTRATION AND PERSISTENCE

C. SOCIAL INTERACTION

D. ADAPTATION

WORK-RELATED FUNCTIONAL LIMITATIONS

1. Would this patient have difficulty working a full 8-hour day due to psychiatric symptoms?
☐ Yes ☐ No

If yes, explain: _____________________________________________________________________________
_____________________________________________________________________________

2. How often would symptoms likely interfere with attention and concentration needed to perform simple, routine tasks?
☐ Never ☐ Rarely ☐ Occasionally ☐ Frequently ☐ Constantly

3. How often would symptoms likely interfere with attention and concentration needed to perform detailed, complex tasks?
☐ Never ☐ Rarely ☐ Occasionally ☐ Frequently ☐ Constantly

4. Would this patient's symptoms be exacerbated by work stress?
☐ Yes ☐ No

If yes, explain: _____________________________________________________________________________

5. What level of work stress can this patient tolerate?
☐ High stress ☐ Moderate stress ☐ Low stress ☐ No stress

6. Estimated absences per month due to psychiatric symptoms or treatment:
☐ None ☐ 1-2 days ☐ 3-4 days ☐ More than 4 days

7. Would this patient likely need unscheduled breaks during a workday?
☐ Yes ☐ No

If yes, how often? _____ times per day for approximately _____ minutes

8. Are there limitations on the type of supervision this patient can tolerate?
☐ No limitations
☐ Needs more than usual supervision
☐ Cannot tolerate close supervision
☐ Needs supportive (non-critical) supervision

9. Are there limitations on social interaction?
☐ No limitations
☐ Should have no public contact
☐ Should have only occasional public contact
☐ Should have no contact with coworkers
☐ Should have only occasional contact with coworkers

DECOMPENSATION HISTORY

Has this patient experienced episodes of decompensation (deterioration in function requiring hospitalization, emergency treatment, or similar intervention)?
☐ Yes ☐ No

If yes:

In your opinion, would minimal increases in mental demands or changes in environment likely cause this patient to decompensate?
☐ Yes ☐ No

PROGNOSIS AND TREATMENT

1. What is your patient's prognosis?
☐ Good - Significant improvement expected
☐ Fair - Some improvement expected with treatment
☐ Guarded - Limited improvement expected
☐ Poor - Little or no improvement expected

2. Is your patient compliant with treatment?
☐ Yes ☐ Partially ☐ No

If not compliant, explain why: _____________________________________________________________________________

3. Are there treatment options that have not yet been tried that might improve function?
☐ Yes ☐ No

If yes, specify: _____________________________________________________________________________

4. Have these limitations lasted or are they expected to last at least 12 consecutive months?
☐ Yes ☐ No ☐ Already lasted 12+ months

ACTIVITIES OF DAILY LIVING

Describe any limitations in activities of daily living observed or reported:

☐ Self-care (hygiene, dressing, feeding)
☐ Household chores
☐ Managing finances
☐ Shopping
☐ Using transportation
☐ Social activities
☐ Other: _________________________________________________

Details:
_____________________________________________________________________________
_____________________________________________________________________________

ADDITIONAL COMMENTS

Please provide any additional information that would help evaluate your patient's ability to sustain full-time competitive employment:

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

PROVIDER CERTIFICATION

I certify that the opinions expressed in this questionnaire are based on my clinical examination and treatment of this patient, my review of available records, and my professional judgment. I have considered the patient's mental health diagnoses, symptoms, and clinical findings in making this assessment. These limitations reflect my assessment of the patient's ability to function in a competitive work environment on a sustained basis.

Provider Signature: _________________________________

Printed Name: _________________________________________________

Credentials: _________________________________________________

Date: _________________

Phone for questions: _________________

Please attach:
☐ Copy of most recent treatment notes
☐ Psychological testing reports (if applicable)
☐ Hospital discharge summaries (if applicable)
☐ CV or qualifications statement

Return completed form to:
_________________________________________________
_________________________________________________
Fax: _________________
Email: _________________________________________________

This medical source statement is requested pursuant to 20 C.F.R. § 404.1513 and § 416.913. Your opinion will be evaluated under 20 C.F.R. § 404.1520c and § 416.920c. Mental functional limitations will be assessed under 20 C.F.R. § 404.1520a and § 416.920a.