Mental Health Multiaxial Assessment Form
Complete this assessment form with the client’s current concerns, clinical axes, psychosocial stressors, functioning level, and clinician summary. The form is designed for a polished, minimal, premium experience.
Assessment Overview
Assessment Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Referring Source / Reason for Assessment
*
Current Primary Concern
*
Overall Symptom Severity
*
Minimal
1
2
3
4
Extreme
5
1 is Minimal, 5 is Extreme
Clinical Multiaxial Assessment
Axis I / Primary clinical symptoms present
*
Anxiety
Depression
Trauma-related symptoms
Mood instability
Obsessive-compulsive symptoms
Psychotic symptoms
Substance use concerns
Sleep disturbance
Eating-related concerns
None reported
Other
Axis II / Personality or developmental concerns observed or reported
*
None reported
Personality-related concerns
Developmental concerns
Attention or impulsivity concerns
Emotional regulation difficulties
Interpersonal difficulties
Other
Axis III / Relevant medical factors affecting mental health
Axis IV / Psychosocial stressors
*
Family
Work/school
Housing
Relationship
Financial
Legal
Grief/loss
Caregiving
Social isolation
Other
Axis V / Global functioning rating
*
Very low
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Very low, 10 is Excellent
Safety and Clinician Notes
Risk concerns observed today
*
No immediate concern
Passive thoughts
Active thoughts
Self-harm urges
Harm to others
Unable to assess
Other
Clinician summary / recommended next steps
*
Submit Assessment
Should be Empty: