MH 713 2019-2026

Social environment Housing Economics Other psychosocial/environmental Axis V Current GAF Access to health care Inadequate information Occupational Involve w/Legal Sys DMH Dual Diagnosis Code III. S. Affect Appropriate Labile Constricted Blunted Flat Worried Rigid Memory Unimpaired Impaired re Immediate Amnesia Perceptual Disturbance Paranoid Nihilistic Grandiose Ideations Phobic Suspicious Obsessive Blames Others Persecutory Assaultive Ideas Magical Thinking Irrational/Excessive Worry Sexual Preoccupation Excessive/Inappropriate Religiosity Behavioral Disturbance None Aggressive Uncooperative Demanding Belligerent Violent Destructive Self-Destructive Poor Impulse Control Manipulative Antisocial Thought Process Disturbances None Apparent Associations Loose Tangential Circumstantial Confabulous Flight of Ideas Word Salad Concentration Intact Impaired by Rumination Thought Blocking Clouding of Consciousness Fragmented Fund of Knowledge Below Average Above Average Expansive Sad Self-Perceptions Depersonalizations Ideas of Reference Situation Remote Delusions Somatic Religious Being Controlled Hallucinations Visual Olfactory Tactile Auditory Command Other Interactional Style Culturally congruent Sensitive Guarded/Suspicious Overly Dramatic Negative Silly Intellectual Functioning Thought Content Disturbance Speech Soft Slowed Mute Pressured Loud Excessive Slurred Incoherent Poverty of Content Orientation Oriented Disoriented to Time Place Person Mood and Affect Mood Euthymic Dysphoric Tearful Irritable Lack of Pleasure Hopeless/Worthless Anxious Known Stressor Abstractions Recent Insight Adequate Minimum Moderate Homicidal Denies Ideation Only Threatening Target Plan Suicidal Concrete Judgments Serial 7 s Suicidality/Homicidality Poor Severe Passive Amotivational Isolated Withdrawn Apathetic Evasive Dependent Disorganized Obsessive/compulsive Ritualistic VIII. Mental Status Evaluation Instructions Check all descriptions that apply General Description Grooming Hygiene Average Dirty Bizarre Comments Well Groomed Odorous Disheveled Eye Contact Normal for culture Little Avoids Erratic Motor Activity Calm Restless Agitated Tremors/Tics Posturing Retarded Akathesis E.P. Destruction of this information is required after the stated purpose of the original request is fulfilled. Name IS Agency Provider Los Angeles County Department of Mental Health ADULT RE-ASSESSMENT Psychiatric Hospitalizations No Updates Updates include the following describe below Outpatient Treatment III. Specialty Mental Health Services Medical Necessity Criteria Medi-Cal Specialty Mental Health Included Diagnosis Significant impairment in life functioning due to the Included Diagnosis Expectation that proposed interventions can impact the client s condition Condition will not be responsive to physical health care based treatment Yes No IV. This confidential information is provided to you in accord with State and Federal laws and regulations including but not limited to applicable Welfare and Institutions code Civil Code and HIPAA Privacy Standards. Summary and Diagnosis I. Diagnostic Summary Be sure to include assessment for risk of suicidal/homicidal behaviors significant strengths/weaknesses observations/descriptions symptoms/impairments in life functioning i.e. Work School Home Community Living Arrangements etc and justification for diagnosis II. Diagnosis check one Principle and one Secondary Axis I Prin Sec Code Sec Nomenclature Medications cannot be prescribed with a deferred diagnosis Axis III Code Code Axis IV Psychological and Environmental Problems which may affect diagnosis treatment or prognosis Primary Problem Check as many that apply Primary support group 2.