Patient: Date of intake interview:

DSM-IV diagnostic impressions:

Axis I:
Axis II:
Axis III:
Axis IV:
Axis V:

1. Does patient have a diagnosable mental disorder? [Put another way, is there evidence of a
dysfunction in one or more core psychological processes that is leading to distress and/or
impairment, and which is atypical of norms for his/her cultural group?]

2. If yes, what seem to be the essential problems/symptoms (which will guide us first to the
appropriate diagnostic category or categories)?

3. Once the likely category is identified, which specific diagnosis within that category seems
the best match for patient’s clinical picture?

4. Is there evidence of a personality disorder? [To decide this, it helps to ponder if the problems
associated with the Axis I disorder – assuming there is one – were removed, would the
patient still have consistent, long-standing problems in living? If yes, then consider the
possibility of an Axis II condition.]

5. Are there any co-morbid disorders? [This maybe more than one disorder on Axis I; one or
more on Axis II; or, one or more on Axis I and on Axis II. Be prudent, though; it’s not a case
of the more the merrier. If problems are adequately explained by one disorder, adding others
to the list may not be appropriate.]

6. Any medical issues requiring mention on Axis III? [Is medical problem directly/biologically
causing the psychiatric problem? is the medical condition indirectly contributing to it? are
treatment issues affected by the presence of the medical issues?]

7. Were there any interpersonal or environmental issues in the recent past that contributed either
to the onset of this most recent episode or to a noticeable worsening of already existing
problems? If so, note them on Axis IV.

8. As compared to other persons of similar background, how should patient’s current overall
level of functioning be characterized? [Express as one specific GAF value from 0-100 on
Axis V. Without overdoing it, lean toward the lower/conservative direction.]