MEMORANDUM FOR (SM name and social)   


FROM CDR, (unit)


SUBJECT:  Notification of Commanding Officer Referral for Mental Health Evaluation (Type:Non-Emergency or Emergency)


References:       (a)  DOD Directive 6490.1, “Mental Health Evaluations of Members of the Armed Forces,”

October 1, 1997

(b)     DOD Instruction 6490.4, “Requirements for Mental Health Evaluations of Members of the Armed Forces,” August 28, 1997

(c)     Section 546 of Public Law 102-484, “National Defense Authorization Act for Fiscal Year 1993,” October 1992

(d)     DID Directive 7050.6, “Military Whistleblower Protection,” July 23, 2007


1.       In accordance with references (a) through (d), this memorandum is to inform you that I am referring you for a mental health evaluation.


2.       The following is a description of your behaviors and/or verbal expressions that I considered in determining the need for a mental health evaluation:


(type description here)


3.       Before making this referral, I consulted with the following mental health care provider about your recent actions:  (Dr. Name) , at the Department of Behavioral Health, Bayne Jones Army Medical Center on (date commander talked to doctor).  (Dr. Name) concurs that this evaluation is warranted and is appropriate.


4.       Per references (a) and (b), you are entitled to the rights listed below:


a)       The right, upon your request, to speak with an attorney who is a member of the Armed Forces or is employed by the Department of Defense who is available for the purpose of advising you of the ways in which you may seek redress should you question this referral.

b)       The right to submit to your Service Inspector General or to the Inspector General of the Department of Defense (IG, DoD) for investigation an allegation that your mental health evaluation referral was a reprisal for making or attempting to make a lawful communication to a Member of Congress, any appropriate authority in your chain of command, an IG, or a member of a DoD audit, inspection, investigation or law enforcement organization or in violation of (DoD Directive 64901, DoD Instruction 6490.1, and/or any applicable Service regulations.

c)       The right to obtain a second opinion and be evaluated by a mental healthcare provider of your own choosing, at your own expense, if reasonably available.  Such an evaluation by an independent mental healthcare provider shall be conducted within a reasonable period of time, usually within 10 business days, and shall not delay nor substitute for an evaluation performed by a DOD mental healthcare provider.

d)       The right to communicate without restriction with an IG, attorney, Member of Congress, or others about your referral for a mental health evaluation.  This provision does not apply to a communication that is unlawful.

e)       The right, except in emergencies, to have at least 2 business days before the scheduled mental health evaluation to meet with an attorney, IG, chaplain, or other appropriate party.  If I believe your situation constitutes an emergency or that your condition appears potentially harmful to your well being and I judge that it is not in your best interest to delay your mental health evaluation for 2 business days, I shall state my reasons in writing as part of the request for the mental health evaluation.

f)         If you are assigned to a naval vessel, deployed, or otherwise geographically isolated because of circumstances related to military duties that make compliance with any of the procedures in paragraphs 3) and 4), above, impractical, I shall prepare and give you a copy of the memorandum setting for the reasons for my inability to comply with these procedures.

g)       You are scheduled to meet with (name of the mental health provider) at Bayne Jones Army Community Hospital, Behavioral Health Clinic on (date) at (time).


5.       The following authorities can assist you if you wish to question this referral:

a)       Military Attorney:  Legal Assistance, (337) 531-2580; Trial Defense, (337) 531-0627

b)       Inspector General:  Fort Polk, 337-531-2100/7878

c)       Other available resources: IG, DoD 1-800-424-9098





(CDR signature block)



I have read the memorandum above and have been provided a copy.


Service member’s signature: ________________________________________  Date: _______________




The Service member declined to sign this memorandum which includes the Service member’s Statement of Rights because (give reason and/or quote Service member).


Witness’s signature:  ______________________________________________  Date: _______________


Witness’s rank and name:  _________________________________________   Date: _______________



(Provide a copy of this memorandum to the Service member.)