Correctional Mental Health Evaluation Form
Comprehensive assessment for individuals in correctional settings
Evaluator Full Name
*
First Name
Last Name
Evaluator Email Address
*
example@example.com
Date of Evaluation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Individual's Full Name
*
First Name
Last Name
Correctional Facility Name
*
Reason for Referral / Presenting Concerns
*
Mental Status Examination
*
Rows
Appearance
Mood
Affect
Speech
Thought Process
Status
Normal
Disheveled
Unkempt
Other
Euthymic
Depressed
Anxious
Irritable
Other
Appropriate
Flat
Blunted
Labile
Other
Normal
Pressured
Slow
Other
Coherent
Tangential
Disorganized
Other
Risk Assessment: Does the individual present any of the following risks? (Select all that apply)
*
Suicide Risk
Self-Harm Risk
Violence/Aggression Risk
Escape Risk
None Identified
Other
Psychiatric History (brief summary, including previous diagnoses, hospitalizations, treatments)
Substance Use History (if applicable)
Current Symptoms Assessment
*
Rows
Severity
Anxiety
1
Depression
2
Hallucinations
3
Delusions
4
Sleep Disturbance
5
Appetite Changes
6
Irritability
7
Impulsivity
8
Evaluator's Recommendations and Plan
*
Submit Evaluation
Should be Empty: