About VA Form 21-0781

Use VA Form 21-0781 if you’ve been diagnosed with a mental health condition related to a traumatic event during your military service, and you want to apply for related benefits or services.

As of June 28, 2024, we’ve discontinued the Statement in Support of Claim for Service Connection for PTSD Secondary to Personal Assault (VA Form 21-0781a). We previously used this form to get more information to support claims for posttraumatic stress disorder (PTSD) related to personal assault. We’ve combined this form into a new PDF version of the Statement in Support of Claimed Mental Health Disorder(s) Due to an In-Service Traumatic Event(s) (VA Form 21-0781). You can download the updated PDF form on this page.

These are some examples of mental health conditions:

• Posttraumatic stress disorder (PTSD)
• Major depressive disorder
• Generalized anxiety disorder
• Bipolar disorder

Traumatic events during your military service can include any of these types of events:

• Combat events, like engaging in combat with enemy forces, experiencing fear of hostile military or terrorist activity, serving in an imminent danger area, or serving as a drone aircraft crew member
• Sexual assault or harassment (also known as military sexual trauma or MST)
• Traumatic personal events, like physical assault, battery, robbery, mugging, stalking, or harassment by a person who wasn’t part of an enemy force, or domestic abuse or harassment by a partner
• Other traumatic events, like getting into a car accident, witnessing a natural disaster, working on burn ward or graves registration, witnessing the death, injury, or threat to another person or to yourself, that was caused by something other than a hostile military or terrorist activity, or experiencing or witnessing friendly fire that occurred on a gunnery range during a training mission

Note: This form is optional. But if you’re submitting a claim related to a mental health condition, this form could help with your claim. We’ll use the information you provide to help identify records and other evidence to support your claim.

We recommend submitting the PDF version of VA Form 21-0781

If you want to provide more information to support a claim related to a mental health condition, we recommend you complete and submit the PDF version of VA Form 21-0781 on this page.

We’ve updated our PDF form to allow you to provide more information to support your claim.

Note: If you’re submitting the PDF version of VA Form 21-0781 to support an online application for disability compensation (VA Form 21-526EZ) related to PTSD, you don’t need to answer the online application’s questions about PTSD. Select I've already filled out VA Form 21-0781/21-0781a and want to upload it.

Downloadable PDF

Online tool

We’ll ask you to complete an online application for disability compensation (VA Form 21-526EZ), and answer questions about your PTSD and the events related to it. We’re still in the process of updating our online tool to match the PDF version of this form. You can use the online tool, but you won’t be able to provide additional information about mental health conditions other than PTSD. If you need to provide additional information about mental health conditions other than PTSD, you should complete and upload the PDF version of VA Form 21-0781 as a supporting document in Step 3: Supporting evidence.