Mental Health Evaluation Staff Evaluations: Mental Health Evaluation Client Name(Required) First Last Client Date of Birth(Required) MM slash DD slash YYYY Client Case/MDOC Number(Required)Date of Evaluation(Required) MM slash DD slash YYYY 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) MM slash DD slash YYYY Δ
