Mental Health Evaluation Form

June 23, 2011

A mental health evaluation form is an especially outlined document which is executed for assessing the psychological level, ability of social behaviour and overall metal condition of an individual. These types of forms are generally used at hospital or by psychiatrists.
Sample Mental Health Evaluation Form:

Name of the individual: _____________

Date of birth: ___/___/ ____

Sex: ______________, Age: _________

Occupation: ______________________

Objective of this mental health evaluation form: ___________________

Is it the first mental health evaluation of the individual: _____________?

Is this individual suffering from any kind of mental disorder?


Any kind of head or brain injury survived by the individual: ___________

Is the candidate ingesting any psychological drugs? _________

Has this individual ever referred to some psychiatrist? ____________

Does the candidate undergo through frequent mood swings? _________

Rate the social behaviour of the individual: _______________________

Is the previous medical history of the candidate enclosed with this form?


Signature of the concerned Authority: __________

Date: ___/___/___


Download Mental Health Evaluation Form in Word Format

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