Alameda County

Department of Behavioral Health Care Services

-Mental Health Division

Discharge Summary with
Multiaxial Diagnosis
Client Name:

Birthdate:	Admit Date:
Chart No:	Reporting Unit:
PSP Client ID No:
Progress and Status Summary: (Please include discharge medications, financial status and living situation).

Rationale for Discharge:

Recommendations/Plans for Future Care: (please include referrals to other services with telephone numbers).

Legal Status:

Multiaxial Diagnosis at Discharge
Axis I: Clinical Disorders and Other Conditions (If none, write “none”)

Dagnostic Code DSM IV Name	(Check one)

Axis II: Personality Disorders (If none, write “none”)

Mental Retardation

Dagnostic Code DSM IV Name	(Check one)
Axis III: General Medical Conditions

Principal

Axis IV: Psychological and Environmental Problems (check all the ones that apply)	(Check one)
A.	Problems with primary support group Specify:
B.	Problems related to the social environment Specify:
C.	Educational problems Specify:
D.	Occupational problems Specify:
E.	Housing problems Specify:
F.	Economic problems Specify:
G.	Problems with access to health care services Specify:
H.	Problems related to interaction with legal system/crime Specify:
I.	Other psychological and environmental problems Specify:
J.	Unknown/Unavailable
AXIS V: Global Assessment of Functioning Scale(GAF) Current Score:
Diagnosis established by:	N/A Date:
Name/Title/Agency

______________________________________ _________________________________ N/A

Clinician Signature Date Physician Signature Date

______________________________________

Supervisor Signature Date

313-CH70 DichargeSumWMultDia.dot (DichargeSumWMultDia)	Page 1 of 2

Discharge Summary w/Multiaxial Diagnosis

Form Template

Form # 313-CH70 (1/96)

Behavioral Health

2000-11-27

CHIANG

BHCS