|
|
DEPARTMENT OF THE ARMY (Letterhead) REPLY TO ATTENTION OF |
|
(Date)
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,”
(b) DOD Instruction 6490.4, “Requirements for Mental
Health Evaluations of Members of the Armed Forces,”
(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.
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,
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
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:
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: _______________
OR
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.)