"REQUEST FOR MENTAL HEALTH CONSULTATION - PDF"
DATE: REQUEST FOR MENTAL HEALTH CONSULTATION (USFK REG 40-216 INSTRUCTION: 1. Unit Commander will fill out one copy and send to appropriate mental hygiene facility. 2. For personnel in the Eighth US Army Stockade, send to Mental Health Clinic, 121st Evac Hosp. 3. A thoroughly completed form will assist us in promptly fulfilling your request. NAME (Last, First, MI) GRADE SSN PMOS/DMOS GT SCOPE ETS DEROS ORGANIZATION (With APO AP) UNIT PHONE TIME IN UNIT TIME IN KOREA TIME IN ARMY 1. REASON FOR REFERRAL: Evaluation required for administrative separation under provisions of ________________________________________________________________. Commander desires advice in handling problem soldier. Individual requests assistance. Other (Specify; e.g., pre-trial evaluation, security clearance, etc.) ___________________________________________________________________. List factors which led you to refer this service member and specify questions you desire answered. 2. The following punishments have been given or are pending: Date Type (Art 15 or CM) Describe Offense Punishment USFK FORM 109-E, 1 JUN 83 REPLACES JK FORM 102, 1 NOV 79, WHICH IS OBSOLETE. 3. This service member has had the following company jobs: List jobs with duties Now do you rate service members performance? 4. Rehabilitative measures attempted (including transfers): 5. Brief description of individual's behavior pattern, style of relating to others, and assessment of assets and liabilities. 6. This service member has been interviewed by his/her CO and explanation has been made as to the reason for this consultation. YES NO TYPED NAME AND GRADE OF COMMANDING OFFICER SIGNATURE