Dd Form 2792 - Family Member Medical Summary (With Instructions) Page 12

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FAMILY MEMBER/PATIENT NAME (Last, First, Middle Initial)
SPONSOR NAME
SPONSOR SSN (Last four)
ADDENDUM 2 - MENTAL HEALTH SUMMARY
: To be completed by a Qualified Clinical Provider
(Continued)
6. TREATMENT PLAN
.
(Related to the patient's mental health condition planned over the next three years)
7. PROGNOSIS
(X one)
EXCELLENT
GOOD
FAIR
POOR
GUARDED
UNSTABLE
NON-COMPLIANT
8. PROVIDERS REQUIRED TO IMPLEMENT TREATMENT PLAN AND FREQUENCY OF VISITS
PSYCHIATRIST
PSYCHOLOGIST
SOCIAL WORKER
OTHER (Specify)
WEEKLY
WEEKLY
WEEKLY
WEEKLY
BI-MONTHLY
BI-MONTHLY
BI-MONTHLY
BI-MONTHLY
MONTHLY
MONTHLY
MONTHLY
MONTHLY
QUARTERLY
QUARTERLY
QUARTERLY
QUARTERLY
BIANNUALLY
BIANNUALLY
BIANNUALLY
BIANNUALLY
ANNUALLY
ANNUALLY
ANNUALLY
ANNUALLY
9. OTHER COMMENTS
(Include additional information that would assist in determining necessary treatments.)
10.a. PROVIDER PRINTED NAME OR STAMP
b. SIGNATURE
c. DATE (YYYYMMDD)
d. TELEPHONE NUMBERS (Include Area Code/Country Code)
e. OFFICIAL E-MAIL ADDRESS
f. MEDICAL SPECIALTY
(1) COMMERCIAL
(2) DSN (Military only)
DD FORM 2792 (ADDENDUM 2) (BACK), AUG 2014
Page 10 of 11 Pages

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