When a Guardian group life claim, such as waiver of premium, rests on a mental health condition, the treating clinician completes this two-page behavioral health assessment. It asks for the chief complaint, DSM-5 diagnoses and contextual factors, symptom severity and history, work advice given, recent test or rating scale scores, clinical observations, medications, the treatment plan, vocational prognosis and the current degree of psychological impairment.
The behavioral health clinician completes all 19 items and signs with specialty. The patient's name, claim and plan numbers identify the file.
Download the current version from the source each time; forms change without notice.
Behavioral Health Assessment Form
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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Item 15 asks whether the patient can return to work, part-time or full-time, in their usual or another occupation, with dates. If not, item 16 asks for the ongoing signs and symptoms that support remaining out and an anticipated return date, and item 17 asks about accommodations.
Yes. The end of the form asks the clinician to provide office visit notes for the period Guardian specifies. The notes support the objective observations of behavior, affect, mood and cognition that item 10 asks the clinician to describe.