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Guardian GG-018097: Mental Functional Capabilities Form

For a disability claim based on a mental health condition, Guardian asks the treating psychiatrist, psychologist or other clinician to rate specific mental work tasks on this form. Each task is scored 0 for no limitation, 1 mild, 2 moderate, 3 severe or UR unable to rate, across general neurocognitive functioning, interpersonal functioning, initiative and persistence, and self-management, with comments supporting the ratings.

Who completes it

The treating provider completes all four rating domains and signs with specialty. The claimant's name, birth date and claim number go at the top.

Submitting and payment

How to submit it
The provider returns it to Guardian Group LTD Claims by mail or fax, or uploads it through Guardian's Secure Channel.
Who pays
The form sets no fee and does not say who pays for completing it.

Good to know

  • Any moderate or severe rating needs clinical evidence in the comments. If a task cannot be rated, the provider describes what clinical evidence would be needed to evaluate it.
  • Mild means the patient occasionally shows a limitation, moderate frequently, and severe consistently, so they cannot perform the task on a routine basis.
  • Initiative and persistence tasks include keeping a schedule and regular attendance, working near others without distraction, and keeping a consistent pace without excessive breaks.
  • Self-management covers hygiene and appropriate behavior, awareness of hazards, inhibiting disruptive behavior, traveling in unfamiliar places and setting goals independently. Companion form GG-014468.

Get the official form

Download the current version from the source each time; forms change without notice.

Mental Functional Capabilities Form

Official pagePDF

How this list is checked

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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Frequently asked questions

What neurocognitive tasks does Guardian's GG-018097 rate?

The general neurocognitive domain rates six abilities: reasoning and problem solving, understanding language and following directions, learning and remembering new information, sustaining attention despite ordinary distractions, responding to questions and processing information, and planning, organizing and executing multi-step tasks.

What does UR mean on Guardian's Mental Functional Capabilities Form?

UR stands for unable to rate: there is not enough information to determine whether the patient has a limitation in that area. When a provider marks UR, Guardian asks them to describe in the comments the clinical evidence needed to evaluate that function.