Initial Psychiatric Assessment Page 4
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5NAME/MRN
Current Risk Assessment:
Danger to SELF (Intent, Plan Means): _______________________________________________________________________
Danger to OTHER (Intent, Plan Means): _____________________________________________________________________
Grave Disability: ________________________________________________________________________________________
Clinical Summary (Optional):
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
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______________________________________________________________________________________________________
Diagnostic Impression: DSM Code and Narrative – Designate diagnosis which is primary focus of treatment with a “P”
_________
_________
Axis I
p / s
_________
_________
Axis I
p / s
_________
_________
Axis I
Axis II
_________
_________
V71.09
799.9
p / s
_________________________________ Check If None
Axis III
CONTRIBUTING STRESSORS – Problems related to:
Axis IV
A – Primary Support
B – Social Environment
C – Education
D – Occupation
E – Housing
F – Economic
G – Access to Health Care
H – Legal System
I – Other/ System/ War
Axis V
CURRENT GAF: __________
HIGHEST GAF PAST YEAR: __________
FUNCTIONAL IMPAIRMENT: (IF MODERATE OR ABOVE, MAY WARRANTS TARGETED CASE MANAGEMENT)
None
Mild
Mod
Severe
None
Mild
Mod
Severe
Family Relations
Peer Relations
Physical Health
Academic/Vocational Performance
Self Care
Substance Abuse
TARGETED SYMPTOMS:
None
Mild
Mod
Severe
None
Mild
Mod
Severe
Cognition/Memory/Thought
Perceptual Disturbance
Attention/Impulsivity
Antisocial Behavior
Socialization/Communication
Destructive/Assaultive
Depressive Symptoms
Mania/Agitation/Lability
Anxiety/Phobia/Panic Attack
Somatic Disturbance
Affect Regulation
Other_______________
MHC113Initial Psychiatric Assessment (9/13)
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