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Prudential GL.2025.117 Behavioral Health Capacity Form

Prudential's Disability Management Services uses this 5-page evaluation when a group disability claim rests on a mental health or cognitive condition. The treating clinician explains why leave from work was recommended, rates mental status, reports brief cognitive screens and daily functioning, and lists treatment and medications. The answers help Prudential judge restrictions, limitations and the expected return to work date.

Who completes it

The attending physician or behavioral health clinician completes Section 2 across pages 1 to 4 and signs the certification in Section 3. Section 1 holds only the claimant's name and claim number, repeated at the top of every page.

Submitting and payment

How to submit it
Fax the completed evaluation to Prudential Disability Management Services at the number printed on each page, with the claimant's name and claim number entered on every page.
Who pays
The form lists no fee, billing code or Prudential payment for completing it.

Good to know

  • This is the March 2026 edition (ED. 03/2026). It opens with the date you recommended the patient stop working and your rationale for leave from work.
  • The mental status grid asks you to circle findings for appearance, motor activity, affect, mood, speech, thought process, hallucinations, delusions, orientation, judgment and suicidal or homicidal risk.
  • Cognitive items ask whether the patient can recall four unrelated words after 5 minutes and perform five serial 7s or 3s, plus any other testing results.
  • A checklist asks whether the patient sees work demands, a poor work evaluation, supervisor conflict, job dissatisfaction, family stressors or financial strain as barriers to returning.

Get the official form

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

Behavioral Health Capacity Evaluation

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 does Prudential's Behavioral Health Capacity Evaluation ask about daily functioning?

Page 4 asks whether the patient can clean and maintain the residence, shop routinely, pay bills and drive regularly, and whether these abilities changed after they stopped working. Page 3 also asks whether the patient can perform activities of daily living, with examples if not.

Does Prudential GL.2025.117 ask about IOP or inpatient treatment?

Yes. It asks whether the patient joined or was referred to an intensive outpatient or partial hospitalization program, and whether they were admitted for inpatient care since going out of work, with dates and location. If not, it asks whether that care was recommended and why not.

What medication details does the Prudential behavioral health evaluation need?

A table on page 4 asks for each medication's name, dosage, frequency, date started, date changed and prescribing doctor, followed by whether there are side effects and a description. Prudential also lists GL.2008.237 as a related behavioral health form.