FUNCTIONAL IMPAIRMENTS: None Mild Mod Severe None Mild Mod Severe Family Relations Substance Use/Abuse Activities of Daily Living School Performance/Employment Self-Care Episodes of decompensation & increase of Food/Shelter symptoms, each of extended duration Social/Peer Relations Other (Describe): Physical Health REQUIRED, describe Impairments checked above: Narrative continued in Addendum AND: Impairment Criteria (must have one of the following): Intervention Criteria (proposed INTERVENTION will….): Significant impairment in an important area of life function. AND Significantly diminish impairment Probability of significant deterioration in an important Prevent significant deterioration in an important area of life AND area of functioning. functioning. (Under 21) Without treatment will not progress (Under 21) Probably allow the child to progress developmentally as AND developmentally as individually appropriate. individually appropriate. None of the above. None of the above AND DSM IV DIAGNOSIS—NOT BY HISTORY, MUST BE CURRENT DIAGNOSTIC FORMULATION Axis I-III: Code Description Check ONE Primary DSM & ICD-10 below Narrative continued in Addendum Axis IV Psychological and Environmental Problems which may affect diagnosis, treatment, or prognosis. Primary Problem#: . Check ALL that apply: Primary support group Social environment Education Occupational Housing Economics Access to health care Involve with legal sys. Other psychosocial/environmental Inadequate information Axis V Current GAF: Diagnosis est. by: On date: INITIAL PLAN (MEDICATION PRESCRIBED/LABS ORDERED/ETC.) My Signature below acknowledges having read and endorsed any prior MH Assessment referenced in this Psychiatric Assessment. Narrative continued in Addendum
FUNCTIONAL IMPAIRMENTS: None Mild Mod Severe None Mild Mod Severe Family Relations Substance Use/Abuse School Performance/Employment Activities of Daily Living Self-Care Episodes of decompensation & increase of symptoms, each of extended duration Food/Shelter Social/Peer Relations Other (Describe): Physical Health Narrative continued in Addendum REQUIRED, describe Impairments checked above: Impairment Criteria (must have one of the following): AND: Intervention Criteria (proposed INTERVENTION will….): Significant impairment in an important area of life function. AND Significantly diminish impairment Probability of significant deterioration in an important area of functioning. AND Prevent significant deterioration in an important area of life functioning. (Under 21) Without treatment will not progress developmentally as individually appropriate. AND (Under 21) Probably allow the child to progress developmentally as individually appropriate. None of the above. AND None of the above DSM IV DIAGNOSIS—NOT BY HISTORY, MUST BE CURRENT DIAGNOSTIC FORMULATION Axis I-III: Code DSM & ICD-10 Description Check ONE Primary below Narrative continued in Addendum Axis IV Psychological and Environmental Problems which may affect diagnosis, treatment, or prognosis. Primary Problem#: . Check ALL that apply: Primary support group Social environment Education Occupational Housing Economics Access to health care Involve with legal sys. Other psychosocial/environmental Inadequate information Axis V Current GAF: Diagnosis est. by: On date: INITIAL PLAN (MEDICATION PRESCRIBED/LABS ORDERED/ETC.) My Signature below acknowledges having read and endorsed any prior MH Assessment referenced in this Psychiatric Assessment. Narrative continued in Addendum
Psych_MH_Assessment.docx