Command-Directed Mental Health Evaluation Form
Please complete the Command-Directed Mental Health Evaluation Form to assist with a comprehensive intake and assessment. Fill out all sections as accurately as possible.
Full Name
*
First Name
Last Name
Date of Evaluation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Role/Position
*
Please Select
Service Member
Supervisor
Commanding Officer
Other
Reason for Referral
*
Fitness for Duty
Behavioral Concerns
Observed Performance Changes
Other
Presenting Concerns
Mood Changes
Anxiety Symptoms
Sleep Difficulties
Interpersonal Issues
Substance Use Concerns
Other
Symptom and Functioning Assessment
Rows
Not at all
Mild
Moderate
Severe
Low Mood
1
2
3
4
Irritability
5
6
7
8
Difficulty Concentrating
9
10
11
12
Sleep Problems
13
14
15
16
Social Withdrawal
17
18
19
20
Current Stress Level (1 = Very Low, 5 = Very High)
1
1
2
3
4
5
5
1 is 1, 5 is 5
Has the individual previously received mental health support?
Yes
No
Unknown
Additional Comments or Observations
Evaluator's Name
*
First Name
Last Name
Submit Evaluation
Should be Empty: