DA Form 3822 Report of Mental Status Evaluation

What Is DA Form 3822?

DA Form 3822, Report of Mental Status Evaluation - or the Army mental status evaluation form - is an official Department of Army (DA) form used to document the results of a service member's behavioral health evaluation. The latest version of the form - often incorrectly referred to as the DD Form 3822 - was released by the DA in March 2017. An up-to-date DA Form 3822 fillable version can be downloaded below.

The DA Form 3822 is a document that incorporates key components required for proper diagnosis of the service member's behavioral health. It is used by Army behavioral health providers as a part of the clinical assessment process in psychiatric practice to receive a clear cross-sectional description of a service member's mental status. This document provides the behavioral service provider with a convenient and structured means to observe, analyze, evaluate, and document the patient's mental state through cognition, perception, behavior, attitude, judgment, insight, and other indications.

The DA 3822 is the only valid form that can be used by behavioral health providers within a Military Treatment Facility to document a behavioral or mental health status of a service member. It is the only document that complies with mandatory school evaluation requirements, administrative separation requirements, and command-directed evaluations. No alternative forms are authorized.

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REPORT OF MENTAL STATUS EVALUATION
For use of this form see, AR 40-66; the proponent agency is OTSG.
SECTION I - REASON FOR BEHAVIORAL HEALTH EVALUATION
Command - Directed Behavioral Health Evaluation
Position of Significant Trust and Authority Evaluation
Advanced School Evaluation
Misconduct Administrative Separation Evaluations
Chapter 5-13/5-17 Administrative Separation Evaluation
Other:
SECTION II - BEHAVIORAL HEALTH DISPOSITION DETERMINATION
SM shows no evidence of an impairing behavioral health disorder. SM is cleared for advanced military training.
SM meets criteria for a
Chapter 5-13
Chapter 5-17 separation. SM currently meets medical retention standards.
No duty limitations due to behavioral health reasons. SM currently meets medical retention standards and is cleared for administrative action.
BH disorder present resulting in duty limitations that may impact deployability - See Profile for details. Profile expires on
SM currently does NOT meet medical retention standards, has surpassed medical retention decision point, and a referral to IDES is indicated.
Further assessment is needed to determine behavioral health medical readiness status.
SECTION III - PERTINENT FINDINGS ON MENTAL STATUS EXAMINATION
Screening performed:
Post-Traumatic Stress Disorder
Depression
Traumatic Brain Injury
Substance Misuse
Sexual Trauma
COGNITION:
Normal
Abnormal
BEHAVIOR:
Normal
Abnormal
PERCEPTIONS:
Normal
Abnormal
IMPULSIVITY:
Normal
Abnormal
BH RISK FOR HARM TO SELF:
Not Elevated
Low
Intermediate
High
BH RISK FOR HARM TO OTHERS:
Not Elevated
Low
Intermediate
High
Details of evaluation:
SECTION IV - DIAGNOSES (ONLY REPORT DIAGNOSES REQUIRED FOR SUPPORTING SECTION II FINDINGS)
BH DIAGNOSES:
OTHER MEDICAL DIAGNOSES:
SECTION V - FOLLOW-UP RECOMMENDATIONS
No follow-up needed
Follow-up recommended (see below)
Follow-up as already scheduled (see below)
Clinic:
Phone:
Location:
Date:
Time:
Recommend command referral to:
FAP
JAG
SUD Evaluation
Other:
PATIENT INFORMATION
Patient Name:
Rank/Grade:
Status:
Prefix:
DOB (YYYYMMDD): Sponsor DOD ID:
MTF Code:
Date:
PATIENT'S IDENTIFICATION (For typed or written entries, give: Name - last, first, middle; grade; date; hospital or medical facility)
PREVIOUS EDITIONS ARE OBSOLETE.
Page 1 of 2
DA FORM 3822, MAR 2017
APD LC v1.03ES
REPORT OF MENTAL STATUS EVALUATION
For use of this form see, AR 40-66; the proponent agency is OTSG.
SECTION I - REASON FOR BEHAVIORAL HEALTH EVALUATION
Command - Directed Behavioral Health Evaluation
Position of Significant Trust and Authority Evaluation
Advanced School Evaluation
Misconduct Administrative Separation Evaluations
Chapter 5-13/5-17 Administrative Separation Evaluation
Other:
SECTION II - BEHAVIORAL HEALTH DISPOSITION DETERMINATION
SM shows no evidence of an impairing behavioral health disorder. SM is cleared for advanced military training.
SM meets criteria for a
Chapter 5-13
Chapter 5-17 separation. SM currently meets medical retention standards.
No duty limitations due to behavioral health reasons. SM currently meets medical retention standards and is cleared for administrative action.
BH disorder present resulting in duty limitations that may impact deployability - See Profile for details. Profile expires on
SM currently does NOT meet medical retention standards, has surpassed medical retention decision point, and a referral to IDES is indicated.
Further assessment is needed to determine behavioral health medical readiness status.
SECTION III - PERTINENT FINDINGS ON MENTAL STATUS EXAMINATION
Screening performed:
Post-Traumatic Stress Disorder
Depression
Traumatic Brain Injury
Substance Misuse
Sexual Trauma
COGNITION:
Normal
Abnormal
BEHAVIOR:
Normal
Abnormal
PERCEPTIONS:
Normal
Abnormal
IMPULSIVITY:
Normal
Abnormal
BH RISK FOR HARM TO SELF:
Not Elevated
Low
Intermediate
High
BH RISK FOR HARM TO OTHERS:
Not Elevated
Low
Intermediate
High
Details of evaluation:
SECTION IV - DIAGNOSES (ONLY REPORT DIAGNOSES REQUIRED FOR SUPPORTING SECTION II FINDINGS)
BH DIAGNOSES:
OTHER MEDICAL DIAGNOSES:
SECTION V - FOLLOW-UP RECOMMENDATIONS
No follow-up needed
Follow-up recommended (see below)
Follow-up as already scheduled (see below)
Clinic:
Phone:
Location:
Date:
Time:
Recommend command referral to:
FAP
JAG
SUD Evaluation
Other:
PATIENT INFORMATION
Patient Name:
Rank/Grade:
Status:
Prefix:
DOB (YYYYMMDD): Sponsor DOD ID:
MTF Code:
Date:
PATIENT'S IDENTIFICATION (For typed or written entries, give: Name - last, first, middle; grade; date; hospital or medical facility)
PREVIOUS EDITIONS ARE OBSOLETE.
Page 1 of 2
DA FORM 3822, MAR 2017
APD LC v1.03ES
SECTION VI - RECOMMENDATIONS AND COMMENTS FOR COMMANDER
Service member can understand and participate in administrative proceedings and appreciate the difference between right and wrong.
Service member's behavioral health condition was a mitigating factor in the alleged behavior leading to administrative separation.
Ensure Service member is able to attend all follow-up appointments.
No safety precautions are indicated.
Restrict access to or disarm all military weapons and ammunition. No range duties.
Encourage Service member to temporarily secure personal weapons with MPs or other trusted source.
Consider placement of Service member in barracks for increased support and potentially reduced access to weapons.
Prohibit use of alcohol. Alcohol can interfere with medications, decrease rational judgment, and increase chance for impulsive acts.
Provide increased leader supervision/support by checking in with Service member at least every
hours each day from first formation until lights
out and ensure Service member does not sleep in a room alone.
Consider no contact order between Service member and
to limit risk of harm to self/others.
If Service member shows concerning changes in mood, behavior, or safety, then command should call: Name:
Phone:
during duty hours. After hours, command should escort Service member to the nearest emergency room.
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.)
Further Comments:
Command representative contacted:
Name:
Duty Position:
Phone:
BEHAVIORAL HEALTH PROVIDER SIGNATURE(S)
Behavioral Health Provider's Signature
Date
Behavioral Health Supervisor Signature (if needed):
Date
PATIENT INFORMATION
Patient Name:
Rank/Grade:
Status:
Prefix:
DOB (YYYYMMDD): Sponsor DOD ID:
MTF Code:
Date:
PATIENT'S IDENTIFICATION (For typed or written entries, give: Name - last, first, middle; grade; hospital or medical facility)
DA FORM 3822, MAR 2017
Page 2 of 2
APD LC v1.03ES

Download DA Form 3822 Report of Mental Status Evaluation

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DA Form 3822 Instructions

The Army policies and guidelines for use of the DA 3822 are provided in Army Regulation 40-66, Medical Record Administration and Healthcare Documentation. Basically, the form is used for:

  • Advanced school evaluation;
  • Mental status evaluation when a service member applies for a position of significant trust and authority;
  • Administrative separation evaluation;
  • Misconduct administrative separation evaluation;
  • Service member's behavioral health evaluation requested by a commander.
  • The commander may request a mental health evaluation if:
  • Service members by words or actions arise suspect of causing injury whether to themselves or to others;
  • Facts and circumstances show the possibility of such injury;
  • The commanding officer believes the subordinates are possibly suffering from a severe mental disorder.

The evaluation instructions are simple:

  1. Determining the need for evaluation, the commander locates the closest Military Treatment Facility that has specialists capable to perform behavioral health evaluation;
  2. The commander finds out the requirements of the facility (e.g., if an escort is needed) and arranges the meeting between the service member in question and a behavioral health provider;
  3. The commander notifies the service member about evaluation and explains the reasons via a memo in compliance with the Department of Defense Instruction 6490.4, Requirements for Mental Health Evaluations of Members of the Armed Forces. No developmental counseling form is used in this case;
  4. The commander must comprehensively explain that the aim of the evaluation is to obtain the information, not to provide treatment;
  5. The commander furnishes behavioral health providers with all the relevant information particularly focusing on the issue that arose the concern;
  6. After visiting the appointed meeting, the service member returns with the filled out DA Form 3822;
  7. The commander examines the information provided via the form and decides how to proceed with the situation;
  8. The commander may request help from the Director of Psychological Health.

The provided instructions and requirements are included in the Army Reserve Psychological Health Program. The main aim of this program is to help Army leaders and units to make an informed decision regarding each case and to provide aid to service members who experience behavioral health issues.

How to Fill out DA Form 3822?

The person responsible for conducting the Army mental status evaluation is a behavioral health provider. The document consists of seven sections, and must include:

  1. Service member's identification information;
  2. Service member's diagnosis;
  3. Fitness for duty determination;
  4. Information about medications and treatment if any;
  5. Recommendations and explanations for commander;
  6. Signature of the behavioral health provider who performed the evaluation.
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