DIAGNOSTIC IMPRESSION (continued) Axis V, Diagnostic Impression, Child GAF Rating: (current) Axis V, Diagnostic Impression, Child GAF Rating: (highest level last 12 months) Diagnostic Impression Comments: Prognosis Prognosis: Fair Excellent Good Guarded Poor       Terminal  Uncertain Prognosis Comments: RECOMMENDATIONS Further Assessments Needed:  No  Yes  Unable to assess Further Assessments Needed Type: Achievement testing  Cognitive function screening Dementia screening    Forensic assessment Functional assessment ICST evaluation    Intellectual functioning  Neuropsychological battery  Neuropsychological screen  Objective personality testing  Projective testing  Substance use assessment Other  (specify) Further Assessment Comments: (Identify if psychiatric stabilization required). (Education to address hospital specific “risk” issues). 11
DIAGNOSTIC IMPRESSION (continued) Axis V, Diagnostic Impression, Child GAF Rating: (current) Axis V, Diagnostic Impression, Child GAF Rating: (highest level last 12 months) Diagnostic Impression Comments: Prognosis Prognosis:  Excellent  Terminal  Good  Uncertain  Fair  Guarded  Poor Prognosis Comments: RECOMMENDATIONS Further Assessments Needed:  No  Yes  Unable to assess Further Assessments Needed Type:  Achievement testing  Forensic assessment  Intellectual functioning  Objective personality testing  Other (specify)  Cognitive function screening  Functional assessment  Neuropsychological battery  Projective testing  Dementia screening  ICST evaluation  Neuropsychological screen  Substance use assessment Further Assessment Comments: (Identify if psychiatric stabilization required). (Education to address hospital specific “risk” issues). 11