Mental Health Evaluation

Staff Evaluations: Mental Health Evaluation

Client Name(Required)

First Last

Client Date of Birth(Required)

Client Case/MDOC Number(Required)

Date of Evaluation(Required)

Referral Source(Required)

Referrer(Required)

First Last

Presenting Problem / Chief Complaint(Required)

Relevant Personal and Psychosocial History(Required)

Mental Health History (diagnoses, treatment, hospitalizations)(Required)

Medical History / Medications(Required)

Mental Status Examination(Required)

Risk Assessment (SI/HI, self-harm, safety concerns)(Required)

Clinical Impression / DSM-5 Diagnosis (with ICD-10 codes)(Required)

Treatment Recommendations(Required)

Evaluator Name(Required)

First Last

Evaluator Title / Credential(Required)

Evaluator License #(Required)

By checking this box, I certify under penalty of perjury under the laws of the State of Michigan that my typed name and submission of this form constitute my true and authorized electronic signature.(Required)

I certify

Evaluator Signature (please type your name)(Required)

Date(Required)