Army Mental Health Evaluation Form
Patient Information
Patient Name
Prefix
First Name
Last Name
Patient Date of Birth
 -
Month
 -
Day
Year
Date
BEHAVIORAL HEALTH DISPOSITION DETERMINATION
SM does not appear to have any behavioral health (BH) issues. SM has received clearance to participate in advanced military training.
There are no restrictions on duties owing to behavioral health issues. SM presently meets the requirements for behavioral health medical retention.
To identify the state of behavioral health medical readiness, more testing is required.
SM does not meet medical retention standards and has reached the point of medical retention determination.
Screening Performed
Depression
Traumatic Brain Injury
Substance Misuse
Sexual Trauma
Post-Traumatic Stress Disorder
Perceptions
Impaired
Not Impaired
Cognition
Impaired
Not Impaired
Impulsivity
Normal
Abnormal
Behavior
Normal
Abnormal
BH Risk for Harm to Self
Low
1
2
3
4
High
5
1 is Low, 5 is High
BH Risk for Harm to Others
Low
1
2
3
4
High
5
1 is Low, 5 is High
Further Information
BH Diagnoses
Other Medical Diagnoses
BH Provider's Signature
BH Supervisor Signature
Submit
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