| CASE NAME OR NUMBER: |
DATE: |
| EXERCISE FOR MULTIAXIAL ASSESSMENT |
| AXIS I: CLINICAL DISORDERS AND OTHER CONDITIONS THAT MAY BE A FOCUS OF THERAPY |
| DIAGNOSTIC CODE |
DSM - IV NAME |
| AXIS II: PERSONALITY DISORDERS MENTAL RETARDATION |
| DIAGNOSTIC CODE |
DSM - IV NAME |
| AXIS III: GENERAL MEDICAL CONDITIONS (List any indications of medical conditions, illness, or injury.) |
| AXIS IV: PSYCHOSOCIAL AND ENVIRONMENTAL STRESSORS (check all that apply and specify) | [ ]Problems with primary support group: | [ ]Problems related to social environment: | [ ]Educational problems: | [ ]Occupational problems: | [ ]Housing problems: | [ ]Economic problems: | [ ]Problems with access to health care: | [ ]Problems related to judicial system: | [ ]Problems with religion: | [ ]Other: |
| AXIS V: GLOBAL ASSESSMENT OF FUNCTIONING SCORE | SCORE: [ ] [ ] [ ] TIME FRAME: |
| AXIS VI: ASSESSMENT OF SPIRITUAL FUNCTIONING | SCORE: [ ] [ ] [ ] TIME FRAME: |