Department of Medical Assistance Services / Local Education Agency Services
Psychiatric, Psychological and Mental Health Services
Diagnostic Interview Examination
90801 Diagnostic Interview Examination
90802 Interactive Diagnostic Interview Examination
Student Name:
Last
Medicaid/FAMIS ID#:
ICD-9 CM Diagnosis Code (required for billing):
Source of Referral:
Reason for Referral:
Presenting Problem:
Medical History:
Current Medication:
Previous Psychiatric/ Psychological Treatment / Intervention:
Relevant Family History:
Educational History:
History of alcohol or drug use:
DMAS 45
RVSD1010
First
Date exam completed:
Mental Status Exam:
Appearance:
Neat & well-groomed
Unkempt
Responsiveness:
Alert
Distracted
Orientation:
X4
Other
Attitude:
Cooperative
Eye Contact:
Appropriate
Motor Behavior:
Normal
Speech:
Spontaneous
Minimally responsive
Slow
Rapid
Slurred
Mumbled
Vocabulary:
Average
Above Average
Below Average
Thought Process:
Logical & goal-directed
Tangential
Circumstantial
Loose Associations
Thought Content:
Passive
Guarded
Intense
Restless
Age-appropriate
DMAS
RVSD1010
Poor
Hyperactive
Preoccupations
Compulsion
Irritable
Hypoactive
Delusion
Phobias
Perception:
Normal
Auditory Hallucinations
Suicidal:
Denied
Ideations
Plan
Intention
Homicidal:
Denied
Ideations
Plan
Intention
Mood:
Calm
Affect:
Appropriate
Inappropriate
Constricted
Labile
Insight:
Good
Fair
Poor
Externalizes
Judgment:
Good
Happy
Anxious
Fair
Depressed
Visual Hallucinations
Irritable
Angry
Poor
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Diagnostic Impression: (Axis I or II required for billing)
Axis I: Clinical Disorders / Other conditions That May Be a Focus of Clinical Attention:
Axis II: Personality Disorders / Mental Retardation:
Axis III: General Medical Conditions-
Axis IV: Psychosocial and Environmental Problems-
Axis V: Global Assessment of Functioning:
Current:
Past Year:
Suggested GAF ranges related to educational settings:
30 & below: hospitalized, residential treatment, specialized programs
30 - 40: violent, acting out
40 - 60: self-contained class, non-violent acting out, social problems
60 - 70: resource/itinerant services
70 & above: adjustment issues, probably not special education; guidance counseling
Recommended Initial Treatment / Intervention Plan:
Frequency of treatment (as applicable):
X/
Clinician’s Signature, Title
Printed Name
DMAS
RVSD1010
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