.............................................................................................................(DATE)

MEMORANDUM FOR (MEMBER'S RANK AND FULL NAME)

SUBJECT: Notice of Schedule of Command-Directed Mental Health Evaluation

1. I have scheduled you for an outpatient mental health evaluation to determine your fitness for duty. This evaluation is scheduled for (DATE, DATE) at (TIME) in the (CLINIC), building (NUMBER) with (RANK AND NAME OF PHYSICIAN) who is the consulting physician. You will pick up your medical records from the (NAME OF HOSPITAL), building (NUMBER), and take them with you to this appointment. I have directed this evaluation for the following reason(s).

a. (BEHAVIOR OR RATIONAL).

b. (BEHAVIOR OR RATIONAL).

c. ETC.

2. You have been referred for this evaluation to determine your suitability to (SITE FINAL OUTCOME DESIRED).

3. In making my decision to refer you for this evaluation, I consulted with (PHYSICIAN'S RANK AND NAME), a mental health professional in the (CLINIC).

4. You have the right to consult with any or all of the following officials: an Inspector General, the Area Defense Counsel or other Air Force Defense Counsel designated by the Chief Circuit Defense Counsel, the Chaplain, your Congressmen. The positions and numbers of those personnel who provide services to personnel at this installation are set out below:

a. Inspector General (IG) XXX-XXXX

b. Area Defense Counsel XXX-XXXX

c. Base Chaplain XXX-XXXX

5. You have the rights listed in Subparagraphs a through f below:

a. Upon your request, the Area Defense Counsel shall advise you in the methods you may use to redress this mental health referral. Per your request, an appointment was made for you by the first sergeant.

b. If you submit a complaint to an Inspector General alleging that you have been referred for this evaluation in violation of Department of Defense Directive 6490.1, the Inspector General, DoD, shall conduct or oversee an investigation of your allegation.

c. You have the right to be evaluated by a mental health professional of your own choosing, if the mental health professional is reasonably available. This evaluation shall be conducted within a reasonable period of time. If the mental health professional is not an employee of DoD, you will be required to pay for the evaluation. Further, even if you request an additional mental health evaluation, it will not require your commander to delay the original mental health evaluation.

d. You have the right to unrestricted access in communicating with an Inspector General, attorney, Congressman, or any other person you choose about this referral for a mental health evaluation. This provision does not apply to communications that would be otherwise unlawful.

e. You have at least two business days before this scheduled mental evaluation to provide you an opportunity to consult with an Inspector General, Attorney, your Congressman, Chaplain, or another appropriate authority regarding this mental health referral.

f. There are no military circumstance which prevent me from providing you with the rights set forth in a through e above.

6. A copy of DoD Directive 6490.1 is available for review in the base publications library.

7. You will acknowledge your receipt of notification and rights by your endorsement below.

..................................................................................(COMMANDER'S SIGNATURE BLOCK)

1st Ind: (MEMBER'S RANK AND LAST NAME)

MEMORANDUM FOR (UNIT/CC)

1. I received this notice at __________________ (time) on ________________ (date). I have been provided a copy of this document. I understand the rights set out in paragraph 5 of the Notice of Mental Health Evaluation. I also understand that I have at least two workdays to consult with appropriate officials prior to my scheduled appointment.

2. I (DO) (DO NOT) waive the rights as detailed above.