Why Records Matter Before the Evaluation Even Begins
An independent psychological evaluation is only as strong as the evidence behind it.
Before Dr. Howard conducts a clinical interview or writes a single word of a report,
he reviews everything available about your service, your medical history, and your
current functioning. That review is not a formality. It shapes the questions asked
during the interview, informs the diagnostic conclusions, and directly affects how
well-supported the final opinion will be.
Veterans who arrive with thorough records tend to receive more comprehensive,
defensible evaluations. The time you invest in gathering records before your
evaluation is time well spent.
The Records Dr. Howard Requests
1. DD-214 – Certificate of Release or Discharge from Active Duty
Your DD-214 is the foundation of any VA-related evaluation. It confirms your branch
of service, dates of active duty, character of discharge, Military Occupational
Specialty, and deployment history. If you served more than one period of active duty
or in more than one branch, provide all DD-214s.
2. VA Rating Decision Letters
Provide all prior VA rating decision letters for all conditions, not just mental
health conditions. These documents tell Dr. Howard which conditions have already
been formally evaluated and rated, what evidence the VA relied on, and what the VA’s
stated reasons were for its conclusions. Understanding what the VA has already
decided, and why, is essential context for an independent evaluation.
3. List of Your Service-Connected Conditions
Be prepared to clearly identify which conditions are officially service-connected.
A service-connected condition is one for which the VA has conducted a formal
evaluation and issued a rating. This is different from a condition you believe began
during service but has not yet been formally adjudicated. That distinction affects
how the evaluation is structured and what the written opinion needs to address.
4. VA Mental Health and Behavioral Health Records
Any records from your VA file documenting mental health evaluations, psychiatric
treatment, counseling, or behavioral health visits, including records from during
or after service. These records establish a documented history of symptoms and
treatment over time.
5. Private and Community Mental Health Records
Records from private providers, community mental health centers, hospitals, or
outpatient clinics documenting mental health treatment after service. Records from
within the first year following discharge are particularly important because they
can establish continuity between in-service experiences and post-service symptoms.
Records from any time period are relevant and helpful.
6. Military Personnel Records
Documentation of deployments, duty assignments, Military Occupational Specialty,
awards, commendations, and disciplinary actions where applicable. Personnel records
can corroborate in-service events and stressors that may not appear in medical
records, particularly for combat deployments or high-stress assignments.
7. Buddy Statements and Lay Statements (VA Form 21-10210)
Written statements from fellow service members, family members, or others who can
attest to changes in your behavior, mental health, or functioning during or after
service. The strongest buddy statements come from people who either witnessed the
relevant events directly or were told about them at or near the time they occurred.
Statements should be specific, including dates, locations, and what the person
observed or was told, rather than general character references. The closer in time
the person’s knowledge is to the actual events, the more weight a VA rater is likely
to give it.
8. Prior C&P Examination Reports and DBQs
Copies of any previous Compensation and Pension exam reports or Disability Benefits
Questionnaires, particularly for mental health conditions. These documents allow
Dr. Howard to understand what prior examiners found, what they may have missed, and
where the existing record is incomplete or inaccurate. They are especially important
if a prior C&P exam resulted in a negative opinion that you are seeking to rebut.
9. Service Treatment Records
Service treatment records can be extremely voluminous and submitting an unfiltered
file of thousands of pages is neither necessary nor helpful. For mental health
claims, focus your search on records that document mental health contacts,
behavioral health referrals, or significant events during service that relate to
your claim.
Your VA rating decision letters already confirm which medical conditions are
service-connected and explain the basis for those determinations. For that reason,
extensive service treatment records related to physical conditions are generally
not needed. If you are claiming a mental health condition secondary to a
service-connected physical disability, the rating decision letter establishing that
physical condition is typically sufficient. Dr. Howard will let you know if anything
additional is needed after reviewing your submitted materials.
10. Documentation of Military Sexual Trauma, if applicable
Any related reports, VA MST coordinator correspondence, buddy statements, or
treatment records, if you are comfortable providing them and they are relevant to
your claim. MST-related documentation carries a relaxed evidentiary standard under
VA rules, and even informal corroborating evidence can be meaningful.
11. Current Treatment Records
Records from any current mental health providers, primary care physicians, or
specialists documenting your present symptoms and level of functioning. Current
records establish that symptoms are ongoing and provide a clinical baseline against
which the evaluation findings can be understood.
12. Completed VA Forms Related to Your Claim
Such as VA Form 21-526EZ (Application for Disability Compensation), VA Form 21-0781
(Statement in Support of Claim for Service Connection for PTSD and Other Mental
Health Conditions), or any Intent to File documentation. These confirm the formal
status of your claim, document your account of in-service events related to mental
health conditions, and identify what conditions are currently under adjudication.
13. Personal Statement or Prior Nexus Letter, if applicable
If you or a representative have already drafted a personal statement describing
your in-service experiences and their impact, or if you have obtained a nexus letter
from another provider, please share a copy. Understanding what has already been
submitted helps Dr. Howard avoid redundancy and ensures the independent evaluation
adds the most value possible to your existing record.
What Happens During the Evaluation
Once Dr. Howard has reviewed your records, he conducts a structured clinical
interview covering your military history, deployment experiences, and any identified
stressors. The interview also addresses your developmental, familial, social,
educational, and occupational history across pre-military, military, and
post-military periods, as well as your current symptoms and how they affect your
daily life and ability to work. Standardized psychological testing may be used where
appropriate.
The time Dr. Howard spends reviewing records and preparing the written report is
part of the evaluation, even when it takes place outside your scheduled appointment.
The more complete your records, the more thoroughly that preparation can be done.
What If You Cannot Obtain Everything
Do not let an incomplete record set stop you from moving forward. Gather what you
can, make a reasonable effort to obtain what is missing, and let Dr. Howard’s office
know what you are still working on. In some cases, gaps in the official record can
be addressed through buddy statements, personal statements, or other corroborating
evidence. A VSO can often help you request records through the VA at no cost.
Military records and service treatment records may also be obtained through a
Freedom of Information Act request at archives.gov.