Command Directed Behavioral Health Evaluation Form

Command Directed Behavioral Health Evaluation Form
Date
MonthDayYear
Date
To:
From:
1- Request a Command Directed Behavioral Evaluation of:
Soldier's Name:
First NameLast Name
Rank:
MOS:
DOB:
TIS:
2- Referred by:
Name:
First NameLast Name
Title/Position:
Rank:
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Email:
example@example.com
3- Reason for Evaluation:
What behaviors or verbal expressions led to the conclusion that the Soldier's performance was being harmed by a behavioral health condition?
1. What is the diagnosis and prognosis for the SM?
2. Is the SM fit for duty?
3. Is this SM subject to any safety precautions?
4. What is the recommended course of action?
4- Military Information:
Any disciplinary issues:
Previous Performance:
Present Performance:
Do you think this soldier should be retained?
Additional comments that may be useful in assisting you with this soldier:
5- Evaluation Information:
Appointment Date
Location:
Provider:
I have counseled the Soldier on the fact that seeking behavioral health care is not stigmatized, and I have notified him of the date, time, location, and provider for this evaluation.
Name of Requestor
First NameLast Name
Date
MonthDayYear
Date
Signature of Requestor
Clear
Should be Empty:

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