Problems related to the social environment: No Yes If yes, describe: Educational problems: No Yes If yes, describe: Occupational problems: No Yes If yes, describe: Housing problems: No Yes If yes, describe: Economic problems: No Yes If yes, describe: Problems with access to health care services: No Yes If yes, describe: Problems with interaction with the legal system/crime: No Yes If yes, describe: Other psychosocial and environmental problems: No Yes If yes, describe: Axis V Current GAF: Highest GAF in Past Year (if known): Individual Served /Family/Guardian Expression of Service Preferences Service Preferences: Treatment Recommendations / Assessed Needs: No Additional Recommendations Clinically Indicated A-Active, ID-Individual Declined, D-Deferred, R-Referred Out (If declined/deferred/referred out, please provide rationale) A ID* D* R* 1. 2. 3. 4. *Individual Declined/Deferred/Referred Rationale(s) (Explain why Individual Declined to work on Need Area; List rationale(s) for why Need Area(s) is Deferred or Referred Out below). None 1. 2. 3. Further Evaluations Needed: None Indicated Psychiatric Psychological Neurological Medical Educational Vocational Visual Auditory Nutritional AOD Assessment Other: of Care/ Indicated Services Recommendation: No change Individual Served/Guardian/Family Response to Recommendations:
No Yes Problems related to the social environment: If yes, describe: No Yes Educational problems: If yes, describe: No Yes Occupational problems: If yes, describe: No Yes Housing problems: If yes, describe: No Yes Economic problems: If yes, describe: No Yes Problems with access to health care services: If yes, describe: No Yes Problems with interaction with the legal system/crime: If yes, describe: No Yes Other psychosocial and environmental problems: If yes, describe: Axis V Current GAF: Highest GAF in Past Year (if known): Individual Served /Family/Guardian Expression of Service Preferences Service Preferences: Treatment Recommendations / Assessed Needs: No Additional Recommendations Clinically Indicated A-Active, ID-Individual Declined, D-Deferred, R-Referred Out (If declined/deferred/referred out, please provide rationale) A ID* D* R* 1. 2. 3. 4. *Individual Declined/Deferred/Referred Rationale(s) (Explain why Individual Declined to work on Need Area; List rationale(s) for why Need Area(s) is Deferred or Referred Out below). None 1. 2. 3. Further Evaluations Needed: None Indicated Psychiatric Visual Psychological Auditory Neurological Nutritional Medical Educational AOD Assessment Vocational Other: of Care/ Indicated Services Recommendation: No change Individual Served/Guardian/Family Response to Recommendations:
NYSCRI-AT_ComprehensiveUpdate.docx