Army Mental Health Evaluation Form

A clinical document that lets behavioral health providers record a soldier's psychological evaluation, including risk levels, diagnoses, and authorization signatures.

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Facility / Unit Name

Patient Name

Nombre

Apellido

Patient Date of Birth

Behavioral Health Disposition Determination

Fit for Duty Requires Follow-up Not Fit for Duty

Screening Performed

Initial Screening Follow-up Screening Emergency Screening

Perceptions

Normal Hallucinations Illusions

Cognition

Alert and Oriented Confusion Memory Impairment

Impulsivity

Low Moderate High

Behavior

Cooperative Agitated Withdrawn

BH Risk for Harm to Self

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

BH Risk for Harm to Others

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

Further Information

BH Diagnoses

Other Medical Diagnoses

BH Provider's Signature

Sign here

BH Supervisor Signature

Sign here

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