DELAWARE DIVISION OF SUBSTANCE ABUSE AND MENTAL HEALTH 
CONSUMER REPORTING FORM — PSYCHIATRIC DIAGNOSIS 


Consumer's Name 

Last First M.I. 

MCI # 

0 0 0 
TREATMENT 
UNIT ID # 

— 
Check One (Axis I or II) to Indicate PRIMARY DIAGNOSIS

Axis I: Clinical Disorders 
Code 

[]

• 
• 
• 

Code 

[] 

Code 

[] 

Axis II: Personality Disorders/Mental Retardation 

• 
• 
• 

Code 

[] 

Code 

[] 

Code 

[] 

Axis III: General Medical Conditions ICD-9-CM Name 
Code 

• 
• 
• 
• 
• 

Code 

Code 

Code 

Code 

Axis IV: Psychosocial and Environmental Problems 
Check: 

. 
Problems with primary support group (Specify) 
. 
Problems related to the social environment (Specify) 
. 
Educational problems (Specify) 
. 
Occupational problems (Specify) 
. 
Housing problems (Specify) 
. 
Economic problems (Specify) 
. 
Problems with access to health care services (Specify) 
. 
Problems related to interaction with the legal system/crime (Specify) 
. 
Other psychosocial and environmental problems (Specify) 
Axis V: Global Assessment of Functioning Scale Score 

Time Frame (Circle One: Current Last Month Last Quarter Last Year Other _______________________________ ) 

Print Name - Physician Formulating/Confirming Diagnosis 

Signature 

DOCUMENT NO. 35-06-10-11-22-04 

/ / 
Staff ID DATE