GLOBAL ASSESSMENT OF FUNCTIONING Scale ... - …

Page 1 of 2 Modified GLOBAL ASSESSMENT of FUNCTIONING Revised (mGAF-R) Name of person being evaluated Optiona required only i needed by your agency or copy is retained in paper clinical record, please prin ): (l:ft (last)_____(first)_____(mi)__ SSN of person being Evaluated: (Required) :___ ___ ___/___ ___/ ___ ___ ___ ___ Date of Birth (Required) : _____/_____/_____ mm dd yyyy Provider Agency Tax ID (Requ red): _____i Gender: (Required) Male Female Date of ASSESSMENT (Required): _____/_____/_____ mm dd yyyy Use the Criteria below to determine the individual s current functional status, then enter rating on back of this form.

Page 2 of 2 40 Major Impairment in Several Areas of Functioning Group D Criteria: -Serious impairment with work, school or housework if a housewife or househusband (e.g., unable to keep job or stay in school, or failing school, or unable to care for family and house)

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  Assessment, Global, Family, Functioning, Global assessment of functioning

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