Da Form 3822 – Fill Out and Use This PDF

REPORT OF MENTAL STATUS EVALUATION

For use of this form see, AR 40-66; the proponent agency is OTSG.

SECTION I - REASON FOR EVALUATION

SECTION II - FITNESS FOR DUTY

FROM A BEHAVIORAL HEALTH STANDPOINT, THE ABOVE SERVICE MEMBER IS DEEMED:
Fit for full duty, including deployment.
Possibly non-deployable due to prescribed medications. Command surgeon waiver		is		is not recommended.
Requires temporary duty limitations and will likely require behavioral health treatment to be restored to full duty.
Unfit for duty due to a personality disorder or other mental condition that does not amount to a medical disability.
Unfit for duty due to a serious mental condition that is not likely to resolve within 1 year.
Further assessment is needed to determine fitness for duty.

SECTION III - PERTINENT FINDINGS ON MENTAL STATUS EXAMINATION

OTHER:

SECTION IV - IMPRESSIONS

IN MY OPINION, THIS SERVICE MEMBER:

Can understand and participate in administrative proceedings

Can appreciate the difference between right and wrong

Meets medical retention requirements (i.e., does not qualify for a Medical Evaluation Board)

Requires further examination or testing to finalize diagnosis and recommendations

Other:

SECTION V - DIAGNOSES (ONLY THOSE REQUIRED FOR ADMINISTRATIVE PROCESSING)

AXIS I (psychiatric conditions):

AXIS II (personality & intelligence disorders):

AXIS III (medical conditions):

PATIENT INFORMATION

Patient Name:

Rank/Grade:

Status:

Prefix:

DOB (YYYYMMDD):

Sponsor SSN:

MTF Code:

Date:

PATIENT'S IDENTIFICATION (For typed or written entries, give: Name - last, first, middle; grade; date; hospital or medical facility)

DA FORM 3822, MAR 2011

PREVIOUS EDITIONS ARE OBSOLETE.

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SECTION VI - PROPOSED TREATMENTS

None

Follow-up appointments:

Clinic:	Phone No:	Location:	Date:	Time:

SECTION VII - RECOMMENDED PRECAUTIONS

(To be followed until no longer deemed necessary by a Behavior Heath Provider)

None.
Ensure the service member attends all follow-up appointments.
Assigned duties should be relatively low-stress and				should not involve leadership responsibilities.
Work hours should not exceed		per day and the service member should have				day(s) off per week.

Restrict access to or disarm all weapons and ammunition (including those that are privately owned).

Prohibit the use of alcohol as alcohol is a CNS depressant and may impair inhibitions and judgment,

Inspect the service member's quarters and secure all hazardous items (e.g., pills, knives, razors, weapons, etc.).

Move the service member into the barracks.

Secure all medications and dispense no more than				days' worth at a time.
Prohibit contact between the service member and						to prevent harm to self or other individual.
Provide increased supervision (i.e., have someone check in with service member at least daily) or ...
Assign someone to monitor the service member every					hours from first formation until lights out, and
ensure he/she does not sleep in a room alone or ...

Provide continuous 24/7 monitoring (e.g., to prevent self-injurious behavior, harm to others, substance use, etc.).

Other:

SECTION VIII - ADDITIONAL COMMENTS

A Temporary Profile with an "S" rating of

is hereby activated, to expire

.

The service member has been screened for Post Traumatic Stress Disorder and mild Traumatic Brain Injury. All positive screens require a

comprehensive evaluation. Results of the screening are as follows:

Post Traumatic Stress Disorder Screening:

Score

Positive

Negative

Service member was referred for: A comprehensive Post Traumatic Stress Disorder evaluation.

Mild Traumatic Brain Injury Screening:

Score

Positive

Negative

Service member was referred for: A comprehensive mild Traumatic Brain Injury evaluation.

The service member may participate in PT as allowed by physical profile, as exercise often improves mood.

The service member meets psychiatric criteria for expeditious administrative separation lAW

Chapter 5-13 or ...

Chapter 5-17 of AR 635-200

(or equivalent regulation from his/her branch of Service).

(See Additional Comments on Page 3)

PATIENT INFORMATION

Patient Name:

Rank/Grade:

Status:

Prefix:

DOB (YYYYMMDD):

Sponsor SSN:

MTF Code:

Date:

PATIENT'S IDENTIFICATION (For typed or written entries, give: Name - last, first, middle; grade; date; hospital or medical facility)

DA FORM 3822, MAR 2011

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SECTION VIII - ADDITIONAL COMMENTS (Continued from previous page)

Service member does not have a severe mental disorder and is not considered mentally disordered. However, he/she has a long-standing disorder of character, behavior and adaptability (i.e., personality disorder).

The Service-member has a condition that is likely to impair his/her judgment or reliability to protect classified information. (If checked, Commanders will ensure prompt notification to the Army Central Clearance Facility IAW AR 380-67 DA Personnel Security Program, by providing an incident report via the Joint Personnel Adjudication System (JPAS) or its successor.) (Provide detail in the remarks section on page 3.)

It is the professional opinion of the undersigned that this service member will not respond to command efforts at rehabilitation (such as transfer, disciplinary action or reclassification), or to any behavioral health treatment methods currently available in the military.

The service member manifests a long-standing, chronic pattern of difficulty adjusting (i.e., Adjustment Disorder) as characterized by: (Provide detail for the option you choose in the remarks section on Page 3.)

The service member shows no evidence of a disorder that would limit his/her potential to succeed in the military. He/she is cleared to participate in advanced military training.

The service member has been screened for Post Traumatic Stress Disorder and Traumatic Brain Injury. These conditions are either not present or, if present, do not meet AR 40-501 criteria for a medical evaluation board. Command is advised to consider the influence of these conditions, if present, when determining final disposition.

If the service member shows signs of further deterioration, command should call: Name:				and Contact
Information:		, during duty hours. After hours, they should escort the service member to the nearest
Emergency Department.

Service member has been screened for substance use disorders (i.e., alcohol and drugs).

Findings:

Other:

REMARKS

BEHAVIORAL HEALTH PROVIDER SIGNATURE(S)

Behavioral Health Provider's Signature

Date

Behavioral Health Supervisory Co-Signature

Date

PATIENT INFORMATION

Patient Name:

Rank/Grade:

Status:

Prefix:

DOB (YYYYMMDD):

Sponsor SSN:

MTF Code:

Date:

PATIENT'S IDENTIFICATION (For typed or written entries, give:

Name - last, first, middle; grade; date; hospital or medical facility)

DA FORM 3822, MAR 2011

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