Form Possible Admin. Da Possible Admin. Da Possible Admin. Data Elements

OMB No. 0930-03xx

Expiration Date: xx/xx/xx

Attachment 7

Possible Administrative Data Elements

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  The OMB control number for this project is 0930-0xxx.  Public reporting burden for this collection of information is estimated to average 60 hours per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 5600 Fishers Lane, Room 15E57-B, Rockville, Maryland, 20857.

Possible Administrative Data Elements

Minimum Data Set Outcome Variables

Client-Level data

Study sites will be asked to submit some recommended administrative data about the individuals enrolled in their CSC program. To minimize burden we have specified the following:

• Data elements are those that are usually collected by sites as a part of their routine practice. A clinician or person familiar with the client may be able to complete most of the questions quickly.

• Most items require only a “yes” or “no” response.

• No changes to the routine of the clinic are required for these items. Within this document, we note these items with the term “if available.”

Minimum Data Set

Client ID#:_____________

Time interval: ___ BASELINE ___ 6 MONTHS ___ 12 MONTHS ___ 18 MONTHS

Date of Completion (MM/DD/YYYY): ___________________

	Data Items
1	Is the person currently participating in the site CSC program? (yes/no)
2	When did the person first enroll in the CSC program? (2-digit month; 2-digit date; 2-digit year)
3	Gender
4	Age
5	Race
6	Marital status (married/unmarried/divorced)
7	Have children? (how many)
8	Insurance (Medicare/Medicaid/Private Insurance/uninsured/other)
9	Approximate date of onset of psychosis
10	Diagnosis (1 or more mental health diagnoses; be sure to include all psychotic disorder diagnosis)
11	Use of antipsychotic medication (which one(s))?
12	Working/employed (yes/no) 12a. If available, full-time or part-time
13	Attending school or a degree granting program (yes/no) 13a. If available, full-time or part-time?
14	Was the person homeless at any time during past 6 months? (yes/no)
15	Current tobacco use (yes/no)
16	Current Alcohol use (yes/no) 16a. If available, Is there an alcohol disorder diagnosis (which diagnosis)?
17	Current Marijuana use (yes/no)
18	Other drugs use current (yes/no) 18a. If available, other than tobacco or alcohol is there a substance abuse diagnosis (which diagnosis)?
19	Psychiatric Inpatient Hospitalization in past 6 months or during the time period that you usually collect (yes/no) 19a. Please specify the time period being reported (weekly, monthly, every 3 months, etc.) 19b. If available, number of admissions 19c. If available, number of days in hospital
20	Emergency department visit for psychiatric reasons in past 6 months? (yes/no) 20a. If available, number of visits
21	In the past 6 months, have there been any legal issues, arrests, on Probation or Parole (yes/no)
22	Modified Colorado Symptom Index (CSI) 22a. If available, Brief Psychiatric Rating Scale (BPRS) 22b. If available, MIRECC-GAF Symptom Scale
23	Global Functioning: Social And Role Scales
24	Lehman Quality of Life Global Scale 24b. If available, MIRECC-GAF Social Functioning Scale 24b. If available, MIRECC-GAF Occupational Functioning Scale
25	If available, has there been a suicide attempt in past 6 months? (yes/no)

Lehman’s Quality of Life Global Rating Scale (a.k.a., Delighted-Terrible Scale)

Client ID#: __________________________

Time interval: ___ BASELINE ___ 6 MONTHS ___ 12 MONTHS ___ 18 MONTHS

Date of Completion (MM/DD/YYYY): _________________

QL-1. How do you feel about your life in general?

Terrible 1

Unhappy 2

Mostly dissatisfied 3

Mixed 4

Mostly satisfied 5

Pleased 6

Delighted 7

Modified Colorado Symptom Index

Client ID#: __________________________

Time interval: ___ BASELINE ___ 6 MONTHS ___ 12 MONTHS ___ 18 MONTHS

Date of Completion (MM/DD/YYYY): _________________

Below is a list of problems that people sometimes have. Please think about how often you experienced certain problems and how much they bothered or distressed you during the past month. For each problem, please pick one answer choice that best describes how often you have had the problem in the past month (30 days).

How often have you experienced these problems?
		Not at all	Once during the month	Several times during the month	Several times a week	At least every day	NR	DK
1	How often have you felt nervous, tense, worried, frustrated, or afraid?	0	1	2	3	4
2	How often have you felt depressed?	0	1	2	3	4
3	How often have you felt lonely?	0	1	2	3	4
4	How often have others told you that you acted “paranoid” or “suspicious”?	0	1	2	3	4
5	How often did you hear voices, or hear and see things that other people didn’t think were there?	0	1	2	3	4
6	How often did you have trouble making up your mind about something, like deciding where you wanted to go or what you were going to do, or how to solve a problem?	0	1	2	3	4
7	How often did you have trouble thinking straight or concentrating on something you needed to do (like worrying so much or thinking about problems so much that you can’t remember or focus on other things)?	0	1	2	3	4
8	How often did you feel that your behavior or actions were strange or different from that of other people?	0	1	2	3	4
9	How often did you feel out of place or like you did not fit in?	0	1	2	3	4
10	How often did you forget important things?	0	1	2	3	4
11	How often did you have problems with thinking too fast (thoughts racing)?	0	1	2	3	4
12	How often did you feel suspicious or paranoid?	0	1	2	3	4
13	How often did you feel like hurting yourself or killing yourself?	0	1	2	3	4
14	How often have you felt like seriously hurting someone else?	0	1	2	3	4

Global Functioning: Social Scale (GF: Social)

Client ID#:_____________

Time interval: ___ BASELINE ___ 6 MONTHS ___ 12 MONTHS ___ 18 MONTHS

Date of Completion (MM/DD/YYYY): ___________________

Date when Provider Last Saw Client (MM/DD/YYYY): _____________________

Role of Provider Giving Rating: ____________________________________

Please rate the patient’s most impaired level of social functioning in the past month. Rate actual functioning regardless of etiology of social problems.

Rating:

Check here if this is a retrospective rating.

Note: The emphasis is on social contact/interactions with people other than family members, unless these are the only interpersonal contacts a person has (e.g., the lower end of the scale). Also note that ratings of intimate relationships are secondary to the rating of primary friendships and should take into account the age of the individual. For example, older individuals may be expected to have intimate relationships involving steady dating, cohabitation, or marriage whereas younger individuals may be expected to have only romantic interests (i.e., flirtations or crushes) or close friendships.

SUPERIOR SOCIAL/INTERPERSONAL FUNCTIONING
Criteria: 10	Superior functioning in a wide range of social and interpersonal activities. Frequently seeks out others and has multiple satisfying interpersonal relationships, including multiple close and casual friends. Is sought out by others because of his or her many positive qualities. Age-appropriate involvement in intimate relationships.
ABOVE AVERAGE SOCIAL/INTERPERSONAL FUNCTIONING
Criteria: 9	Good functioning in all social areas, and interpersonally effective. Interested and involved in a wide range of social and interpersonal activities, including both close and casual friends. Age-appropriate involvement in intimate relationships. No more than everyday interpersonal problems or concerns (e.g., an occasional argument with spouse, girlfriend/boyfriend, friends, coworkers, or classmates). Able to resolve such conflicts appropriately.
GOOD SOCIAL/INTERPERSONAL FUNCTIONING
Criteria: 8	Some transient mild impairment in social functioning. Mild social impairment is present, but transient and expectable reactions to psychosocial stressors (e.g., after minor arguments with spouse, girlfriend/boyfriend, friends, coworkers, or classmates). Has some meaningful interpersonal relationships with peers (casual and close friends), and/or age-appropriate intimate relationships. Infrequent interpersonal conflict with peers.
MILD PROBLEMS IN SOCIAL/INTERPERSONAL FUNCTIONING
Criteria: 7	Some persistent mild difficulty in social functioning. Mild impairment present that is NOT just expectable reaction to psychosocial stressors (e.g., mild conflicts with peers, coworkers or classmates; difficulty resolving conflicts appropriately). Has some meaningful interpersonal relationships with peers (casual and/or close friends). Some difficulty developing or maintaining age-appropriate intimate relationships (e.g., multiple short-term relationships).
MODERATE IMPAIRMENT IN SOCIAL/INTERPERSONAL FUNCTIONING
Criteria: 6	Moderate impairment in social functioning. Moderate impairment present (e.g., few close friends; significant but intermittent conflicts with peers, coworkers, or classmates). Moderate difficulty developing age-appropriate intimate relationships (e.g., infrequent dating). Occasionally seeks out others but will respond if invited by others to participate in an activity.
SERIOUS IMPAIRMENT IN SOCIAL/INTERPERSONAL FUNCTIONING
Criteria: 5	Serious impairment in social functioning. No close friends or intimate partner, but has some casual social contacts (e.g., acquaintances, school/work friends only). Rarely seeks out others. Occasional combative or verbally argumentative behavior with peers. Beginning to withdraw from family members (e.g., does not initiate conversation with family, but will respond if addressed).
MAJOR IMPAIRMENT IN SOCIAL AND INTERPERSONAL FUNCTIONING
Criteria: 4	Major impairment in social functioning. Serious impairment in relationships with friends or peers (e.g., very few or no friends, frequent conflicts with friends, or frequently avoids friends). Frequent combative or verbally argumentative behavior with peers. Infrequent contact with family members (e.g., sometimes does not respond to family or avoids family members).
MARGINAL ABILITY TO FUNCTION SOCIALLY
Criteria: 3	Marginal ability to function socially or maintain interpersonal relationships. Frequently alone and socially isolated. Serious impairment in relationships with all peers, including acquaintances. Few interactions with family members (e.g., often alone in room). Serious impairment in communication with others (e.g., avoids participating in most social activities).
INABILITY TO FUNCTION SOCIALLY
Criteria: 2	Unable to function socially or to maintain any interpersonal relationships. Typically alone and socially isolated. Rarely leaves home. Rarely answers the phone or the door. Rarely participates in interactions with others at home or in other settings (e.g., work, school).
EXTREME SOCIAL ISOLATION
Criteria: 1	Extreme social isolation. No social or family member contact at all. Does not leave home. Refuses to answer the phone or door.

Global Functioning: Role Scale (GF: Role)

Client ID#:_____________

Time interval: ___ BASELINE ___ 6 MONTHS ___ 12 MONTHS ___ 18 MONTHS

Date of Completion:______________

Date when Provider Last Saw Client: _________________

Role of Provider Giving Rating: ____________________________________

Please rate the patient’s most impaired level of functioning in occupational, educational, and/or homemaker roles, as appropriate, in the past month. Rate actual functioning regardless of etiology of occupational/educational problems.

Rating:

Check here if this is a retrospective rating.

NOTE: This scale emphasizes the level of support provided within the individual’s environment and the individual’s performance given such support. The term “independently” as used throughout this instrument implies that an individual is functioning at an age-appropriate level without the assistance of external supports or accommodations. Examples of independent functioning include (1) age-appropriate functioning in a mainstream school without out requiring extra help, special classes, or special accommodations for testing, (2) competitive full-time employment without additional guidance, support, job coaching, or other forms of special assistance, and (3) full-time homemaker responsible for generating, organizing and pacing of household tasks and activities for a family without additional guidance, support or supervision.

SUPERIOR ROLE FUNCTIONING
Criteria: 10	Independently maintains superior functioning in demanding roles. Obtains only superior performance evaluations at competitive work placement. Obtains all A’s in mainstream school. Generates, organizes & completes all homemaking tasks with ease.
ABOVE AVERAGE ROLE FUNCTIONING
Criteria: 9	Independently maintains very good functioning in demanding roles. Rarely absent or unable to perform. Obtains good to superior performance evaluations at competitive work placement. Obtains grades in A and B range in all courses in mainstream school. Generates, organizes and completes all homemaking tasks.
GOOD ROLE FUNCTIONING
Criteria: 8	Independently maintains good role functioning in demanding roles. Occasionally falls behind on tasks BUT always catches up. Obtains satisfactory performance evaluations at competitive work placement. Obtains grades of C and above in mainstream school. Occasional difficulty generating or organizing homemaking tasks. Or Maintains above average performance with minimal support (e.g., tutoring; reduced academic course load at 4-year university; attends community college; may receive additional guidance at work less than 1-2x week). Receives As & Bs, good work/school evaluations, completes all tasks with this level of support.
MILD IMPAIRMENT IN ROLE FUNCTIONING
Criteria: 7	Mildly impaired functioning in demanding roles independently. Frequently behind on tasks or unable to perform. Frequently obtains poor performance evaluations at competitive work placement or grades of Ds or better in mainstream school. Frequent difficulty generating or organizing homemaking tasks. Or Maintains good performance with minimal support (e.g., minimal accommodations in general education classroom; receives additional guidance/support at work 1-2x week). Receives Cs or higher, satisfactory work/school evaluations, and completes most homemaking tasks with this level of support.
MODERATE IMPAIRMENT IN ROLE FUNCTIONING
Criteria: 6	Moderate impairment independently. May receive occasional F in mainstream courses, persistently poor performance evaluations at competitive work placement, may change jobs because of poor performance, persistent difficulty generating or organizing homemaking tasks. Or Requires partial support (some resource or special education courses; receives guidance/support at work 2+ times/week). May requires less demanding or part-time jobs and/or some supervision in home environment BUT functions well or adequately given these supports (may fall behind but eventually completes assigned tasks, obtains satisfactory evaluations at work or passing grades in school).
SERIOUS IMPAIRMENT IN ROLE FUNCTIONING
Criteria: 5	Serious impairment independently. Failing multiple courses in mainstream school, may lose job, or unable to complete most homemaking tasks independently. Or In entirely special education classes, requires less demanding job/daily support or guidance, may require vocational rehabilitation , and/or some supervision in home environment BUT maintains above average performance - receives As & Bs, good evaluations at work/school, completes all tasks.
MAJOR IMPAIRMENT IN ROLE FUNCTIONING
Criteria: 4	Very serious impairment independently. All Fs in mainstream school or failing out of school. Can’t obtain or hold independent job, or unable to complete virtually any homemaking tasks independently. Or Adequate to good functioning with major support. Requires assisted work environment, entirely special education classes, non-public or psychiatric school, home schooling for the purpose of a supportive school environment, and/or supported home environment BUT functions adequately given these supports (may fall behind but completes assigned tasks, obtains satisfactory performance evaluations at work or passing grades).
MARGINAL ABILITY TO FUNCTION
Criteria: 3	Impaired functioning with major support. Requires supported work environment, entirely special education classes, non-public or psychiatric school, home schooling for the purpose of a supportive school environment, and/or supported home environment BUT functions poorly despite these supports (persistently behind on tasks, frequently unable to perform, obtains poor performance evaluations at work or fails courses at school).
INABILITY TO FUNCTION
Criteria: 2	Disabled but participates in structured activities. On disability or equivalent non-independent status. Not working for pay, attending classes for grades, or living independently. Spends 5 or more hours a week in structured role-related activities (e.g., residential treatment, volunteering, tutoring, sheltered work programs).
EXTREME ROLE DYSFUNCTION
Criteria: 1	Severely disabled. On disability or equivalent non-independent status. Not working for pay, attending classes for grades, or living independently. Spends fewer than 5 hours a week in structured role-related activities.

Brief Psychiatric Rating Scale (BPRS) – Anchors
Expanded Version (4.0)

Introduction

This section reproduces an interview schedule, symptom definitions, and specific anchor points for rating symptoms on the BPRS.

Scale Items and Anchor Points

• Rate items 1–10 on the basis of individual’s self-report.

• Items 11–18 are rated on the basis of observed behavior and speech.

1. Somatic Concern

Degree of concern over present bodily health. Rate the degree to which physical health is perceived as a problem by the individual, whether complaints have realistic basis or not. Somatic delusions should be rated in the severe range with or without somatic concern. Note: be sure to assess the degree of impairment due to somatic concerns only and not other symptoms, e.g., depression. In addition, if the individual rates 6 or 7 due to somatic delusions, then you must rate Unusual Thought Content at least 4 or above.

0. Not Assessed.

1. Not Present.

2. Very Mild. Occasional somatic concerns that tend to be kept to self.

3. Mild. Occasional somatic concerns that tend to be voiced to others (e.g., family, doctor).

4. Moderate. Frequent expressions of somatic concern or exaggerations of existing ills OR some preoccupation, but no impairment in functioning. Not delusional.

5. Moderately Severe. Frequent expressions of somatic concern or exaggerations of existing ills OR some preoccupation and moderate impairment of functioning. Not delusional.

6. Severe. Preoccupation with somatic complaints with much impairment in functioning OR somatic delusions without acting on them or disclosing to others.

7. Extremely Severe. Preoccupation with somatic complaints with severe impairment in functioning OR somatic delusions that tend to be acted on or disclosed to others.

Prompts

• “Have you been concerned about your physical health?” “Have you had any physical illness or seen a medical doctor lately? (What does your doctor say is wrong? How serious is it?)”

• “Has anything changed regarding your appearance?”

• “Has it interfered with your ability to perform your usual activities and/or work?” “Did you ever feel that parts of your body had changed or stopped working?” [If individual reports any somatic concerns/delusions, ask the following]:

• “How often are you concerned about [use individual’s description]?” “Have you expressed any of these concerns to others?”

2. Anxiety

Reported apprehension, tension, fear, panic or worry. Rate only the individual’s statements - not observed anxiety which is rated under Tension.

0. Not Assessed.

1. Not Present.

2. Very Mild. Reports some discomfort due to worry OR infrequent worries that occur more than usual for most normal individuals.

3. Mild. Worried frequently but can readily turn attention to other things.

4. Moderate. Worried most of the time and cannot turn attention to other things easily but no impairment in functioning OR occasional anxiety with autonomic accompaniment but no impairment in functioning.

5. Moderately Severe. Frequent, but not daily, periods of anxiety with autonomic accompaniment OR some areas of functioning are disrupted by anxiety or worry.

6. Severe. Anxiety with autonomic accompaniment daily but not persisting throughout the day OR many areas of functioning are disrupted by anxiety or constant worry.

7. Extremely Severe. Anxiety with autonomic accompaniment persisting throughout the day OR most areas of functioning are disrupted by anxiety or constant worry.

Prompts

• “Have you been worried a lot during [mention time frame]? Have you been nervous or apprehensive? (What do you worry about?)”

• “Are you concerned about anything? How about finances or the future?”

• “When you are feeling nervous, do your palms sweat or does your heart beat fast (or shortness of breath, trembling, choking)?”

• [If individual reports anxiety or autonomic accompaniment, ask the following]: “How much of the time have you been [use individual’s description]?”

• “Has it interfered with your ability to perform your usual activities/work?”

3. Depression

Include sadness, unhappiness, anhedonia and preoccupation with depressing topics (can’t attend to TV or conversations due to depression), hopeless, loss of self-esteem (dissatisfied or disgusted with self or feelings of worthlessness). Do not include vegetative symptoms, e.g., motor retardation, early waking or the amotivation that accompanies the deficit syndrome.

0. Not Assessed.

1. Not Present.

2. Very Mild. Occasionally feels sad, unhappy or depressed.

3. Mild. Frequently feels sad or unhappy but can readily turn attention to other things.

4. Moderate. Frequent periods of feeling very sad, unhappy, moderately depressed, but able to function with extra effort.

5. Moderately Severe. Frequent, but not daily, periods of deep depression OR some areas of functioning are disrupted by depression.

6. Severe. Deeply depressed daily but not persisting throughout the day OR many areas of functioning are disrupted by depression.

7. Extremely Severe. Deeply depressed daily OR most areas of functioning are disrupted by depression.

Prompts

• “How has your mood been recently? Have you felt depressed (sad, down, unhappy, as if you didn’t care)?”

• “Are you able to switch your attention to more pleasant topics when you want to?”

• “Do you find that you have lost interest in or get less pleasure from things you used to enjoy, like family, friends, hobbies, watching TV, eating?”

• [If individual reports feelings of depression, ask the following]:

• “How long do these feelings last?” “Has it interfered with your ability to perform your usual activities?”

4. Guilt

Overconcern or remorse for past behavior. Rate only individual’s statements, do not infer guilt feelings from depression, anxiety, or neurotic defenses. Note: if the individual rates 6 or 7 due to delusions of guilt, then you must rate Unusual Thought Content at least 4 or above, depending on level of preoccupation and impairment.

0. Not Assessed.

1. Not Present.

2. Very Mild. Concerned about having failed someone, or at something, but not preoccupied. Can shift thoughts to other matters easily.

3. Mild. Concerned about having failed someone, or at something, with some preoccupation. Tends to voice guilt to others.

4. Moderate. Disproportionate preoccupation with guilt, having done wrong, injured others by doing or failing to do something, but can readily turn attention to other things.

5. Moderately Severe. Preoccupation with guilt, having failed someone or at something, can tum attention to other things, but only with great effort. Not delusional.

6. Severe. Delusional guilt OR unreasonable self-reproach very out of proportion to circumstances. Moderate preoccupation present.

7. Extremely Severe. Delusional guilt OR unreasonable self-reproach grossly out of proportion to circumstances. Individual is very preoccupied with guilt and is likely to disclose to others or act on delusions.

Prompts

• “Is there anything you feel guilty about? Have you been thinking about past problems?” “Do you tend to blame yourself for things that have happened?”

• “Have you done anything you’re still ashamed of?”

• [If individual reports guilt/remorse/delusions, ask the following]:

• “How often have you been thinking about [use individual’s description]?” “Have you disclosed your feelings of guilt to others?”

5. Hostility

Animosity, contempt, belligerence, threats, arguments, tantrums, property destruction, fights, and any other expression of hostile attitudes or actions. Do not infer hostility from neurotic defenses, anxiety or somatic complaints. Do not include incidents of appropriate anger or obvious self-defense.

0. Not Assessed.

1. Not Present.

2. Very Mild. Irritable or grumpy, but not overtly expressed.

3. Mild. Argumentative or sarcastic.

4. Moderate. Overtly angry on several occasions OR yelled at others excessively.

5. Moderately Severe. Has threatened, slammed about or thrown things.

6. Severe. Has assaulted others but with no harm likely, e.g., slapped or pushed, OR destroyed property, e.g., knocked over furniture, broken windows.

7. Extremely Severe. Has attacked others with definite possibility of harming them or with actual harm, e.g., assault with hammer or weapon.

Prompts

• “How have you been getting along with people (family, co-workers, etc.)?”

• “Have you been irritable or grumpy lately? (How do you show it? Do you keep it to yourself?”

• “Were you ever so irritable that you would shout at people or start fights or arguments? (Have you found yourself yelling at people you didn’t know?)”

• “Have you hit anyone recently?”

6. Grandiosity

Exaggerated self-opinion, self-enhancing conviction of special abilities or powers or identity as someone rich or famous. Rate only individual’s statements about himself, not his/her demeanor. Note: if the individual rates 6 or 7 due to grandiose delusions, you must rate Unusual Thought Content at least 4 or above.

0. Not Assessed.

1. Not Present.

2. Very Mild. Feels great and denies obvious problems, but not unrealistic.

3. Mild. Exaggerated self-opinion beyond abilities and training.

4. Moderate. Inappropriate boastfulness, e.g., claims to be brilliant, insightful or gifted beyond realistic proportions, but rarely self-discloses or acts on these inflated self­ concepts. Does not claim that grandiose accomplishments have actually occurred.

5. Moderately Severe. Same as 4 but often self-discloses and acts on these grandiose ideas. May have doubts about the reality of the grandiose ideas. Not delusional.

6. Severe. Delusional – claims to have special powers like ESP, to have millions of dollars, invented new machines, worked at jobs when it is known that he/she was never employed in these capacities, be Jesus Christ, or the Prime Minister. Individual may not be very preoccupied.

7. Extremely Severe. Delusional – same as 6 but individual seems very preoccupied and tends to disclose or act on grandiose delusions.

Prompts

• “Is there anything special about you? Do you have any special abilities or powers? Have you thought that you might be somebody rich or famous?”

• [If the individual reports any grandiose ideas/delusions, ask the following]:

• “How often have you been thinking about [use individual’s description]? Have you told anyone about what you have been thinking? Have you acted on any of these ideas?”

7. Suspiciousness

Expressed or apparent belief that other persons have acted maliciously or with discriminatory intent. Include persecution by supernatural or other non-human agencies (e.g., the devil). Note: ratings of 3 or above should also be rated under Unusual Thought Content.

0. Not Assessed.

1. Not Present.

2. Very Mild. Seems on guard. Reluctant to respond to some ‘personal’ questions. Reports being overly self-conscious in public.

3. Mild. Describes incidents in which others have harmed or wanted to harm him/her that sound plausible. Individual feels as if others are watching, laughing or criticizing him/her in public, but this occurs only occasionally or rarely. Little or no preoccupation.

4. Moderate. Says other persons are talking about him/her maliciously, have negative intentions or may harm him/her. Beyond the likelihood of plausibility, but not delusional. Incidents of suspected persecution occur occasionally (less than once per week) with some preoccupation.

5. Moderately Severe. Same as 4, but incidents occur frequently, such as more than once per week. Individual is moderately preoccupied with ideas of persecution OR individual reports persecutory delusions expressed with much doubt (e.g., partial delusion).

6. Severe. Delusional – speaks of Mafia plots, the FBI or others poisoning his/her food, persecution by supernatural forces.

7. Extremely Severe. Same as 6, but the beliefs are bizarre or more preoccupying. Individual tends to disclose or act on persecutory delusions.

Prompts

• “Do you ever feel uncomfortable in public? Does it seem as though others are watching you? Are you concerned about anyone’s intentions toward you? Is anyone going out of their way to give you a hard time, or trying to hurt you? Do you feel in any danger?”

• [If individual reports any persecutory ideas/delusions, ask the following]:

• “How often have you been concerned that [use individual’s description]? Have you told anyone about these experiences?”

8. Hallucinations

Reports of perceptual experiences in the absence of relevant external stimuli. When rating degree to which functioning is disrupted by hallucinations, include preoccupation with the content and experience of the hallucinations, as well as functioning disrupted by acting out on the hallucinatory content (e.g., engaging in deviant behavior due to command hallucinations). Include thoughts aloud (‘gedenkenlautwerden’) or pseudohallucinations (e.g., hears a voice inside head) if a voice quality is present.

0. Not Assessed.

1. Not Present.

2. Very Mild. While resting or going to sleep, sees visions, smells odors or hears voices, sounds, or whispers in the absence of external stimulation, but no impairment in functioning.

3. Mild. While in a clear state of consciousness, hears a voice calling the individual’s name, experiences non-verbal auditory hallucinations (e.g., sounds or whispers), formless visual hallucinations or has sensory experiences in the presence of a modality­ relevant stimulus (e.g., visual illusions) infrequently (e.g., 1-2 times per week) and with no functional impairment.

4. Moderate. Occasional verbal, visual, gustatory, olfactory or tactile hallucinations with no functional impairment OR non-verbal auditory hallucinations/visual illusions more than infrequently or with impairment.

5. Moderately Severe. Experiences daily hallucinations OR some areas of functioning are disrupted by hallucinations.

6. Severe. Experiences verbal or visual hallucinations several times a day OR many areas of functioning are disrupted by these hallucinations.

7. Extremely Severe. Persistent verbal or visual hallucinations throughout the day OR most areas of functioning are disrupted by these hallucinations.

Prompts

• “Do you ever seem to hear your name being called?”

• “Have you heard any sounds or people talking to you or about you when there has been nobody around?

• [If hears voices]:

• “What does the voice/voices say? Did it have a voice quality?”

• “Do you ever have visions or see things that others do not see? What about smell odors that others do not smell?”

• [If the individual reports hallucinations, ask the following]:

• “Have these experiences interfered with your ability to perform your usual activities/work? How do you explain them? How often do they occur?”

9. Unusual Thought Content

Unusual, odd, strange, or bizarre thought content. Rate the degree of unusualness, not the degree of disorganization of speech. Delusions are patently absurd, clearly false or bizarre ideas that are expressed with full conviction. Consider the individual to have full conviction if he/she has acted as though the delusional belief was true. Ideas of reference/persecution can be differentiated from delusions in that ideas are expressed with much doubt and contain more elements of reality. Include thought insertion, withdrawal and broadcast. Include grandiose, somatic and persecutory delusions even if rated elsewhere. Note: if Somatic Concern, Guilt, Suspiciousness or Grandiosity are rated 6 or 7 due to delusions, then Unusual Thought Content must be rated 4 or above.

0. Not Assessed.

1. Not Present.

2. Very Mild. Ideas of reference (people may stare or may laugh at him), ideas of persecution (people may mistreat him). Unusual beliefs in psychic powers, spirits, UFOs, or unrealistic beliefs in one’s own abilities. Not strongly held. Some doubt.

3. Mild. Same as 2, but degree of reality distortion is more severe as indicated by highly unusual ideas or greater conviction. Content may be typical of delusions (even bizarre), but without full conviction. The delusion does not seem to have fully formed, but is considered as one possible explanation for an unusual experience.

4. Moderate. Delusion present but no preoccupation or functional impairment. May be an encapsulated delusion or a firmly endorsed absurd belief about past delusional circumstances.

5. Moderately Severe. Full delusion(s) present with some preoccupation OR some areas of functioning disrupted by delusional thinking.

6. Severe. Full delusion(s) present with much preoccupation OR many areas of functioning are disrupted by delusional thinking.

7. Extremely Severe. Full delusion(s) present with almost total preoccupation OR most areas of functioning disrupted by delusional thinking.

Prompts

• “Have you been receiving any special messages from people or from the way things are arranged around you? Have you seen any references to yourself on TV or in the newspapers?”

• “Can anyone read your mind?”

• “Do you have a special relationship with God?”

• “Is anything like electricity, X-rays, or radio waves affecting you?” “Are thoughts put into your head that are not your own?”

• “Have you felt that you were under the control of another person or force?” [If individual reports any odd ideas/delusions, ask the following]:

• “How often do you think about [use individual’s description]?”

• “Have you told anyone about these experiences? How do you explain the things that have been happening [specify]?”

• Rate items 12-13 on the basis of individual’s self-report and observed behavior.

10. Disorientation

Does not comprehend situations or communications, such as questions asked during the entire BPRS interview. Confusion regarding person, place, or time. Do not rate if incorrect responses are due to delusions.

0. Not Assessed.

1. Not Present.

2. Very Mild. Seems muddled or mildly confused 1-2 times during interview. Oriented to person, place and time.

3. Mild. Occasionally muddled or mildly confused 3-4 times during interview. Minor inaccuracies in person, place, or time, e.g., date off by more than 2 days, or gives wrong division of hospital or community center.

4. Moderate. Frequently confused during interview. Minor inaccuracies in person, place, or time are noted, as in 3 above. In addition, may have difficulty remembering general information, e.g., name of Prime Minister.

5. Moderately Severe. Markedly confused during interview, or to person, place, or time. Significant inaccuracies are noted, e.g., date off by more than one week, or cannot give correct name of hospital. Has difficulty remembering personal information, e.g., where he/she was born or recognizing familiar people.

6. Severe. Disoriented as to person, place, or time, e.g., cannot give correct month and year. Disoriented in 2 out of 3 spheres.

7. Extremely Severe. Grossly disoriented as to person, place, or time, e.g., cannot give name or age. Disoriented in all three spheres.

Prompts

• “May I ask you some standard questions we ask everybody?”

• “How old are you? What is the date [allow 2 days]”

• “What is this place called? What year were you born? Who is the Prime Minister?” Rate items 15-24 on the basis of observed behavior and speech.

11. Conceptual Disorganization

Degree to which speech is confused, disconnected, vague or disorganized. Rate tangentiality, circumstantiality, sudden topic shifts, incoherence, derailment, blocking, neologisms, and other speech disorders. Do not rate content of speech.

0. Not Assessed.

1. Not Present.

2. Very Mild. Peculiar use of words or rambling but speech is comprehensible.

3. Mild. Speech a bit hard to understand or make sense of due to tangentiality, circumstantiality, or sudden topic shifts.

4. Moderate. Speech difficult to understand due to tangentiality, circumstantiality, idiosyncratic speech, or topic shifts on many occasions OR 1-2 instances of incoherent phrases.

5. Moderately Severe. Speech difficult to understand due to circumstantiality, tangentiality, neologisms, blocking or topic shifts most of the time, OR 3-5 instances of incoherent phrases.

6. Severe. Speech is incomprehensible due to severe impairment most of the time. Many BPRS items cannot be rated by self-report alone.

7. Extremely Severe. Speech is incomprehensible throughout interview.

12. Blunted Affect

Restricted range in emotional expressiveness of face, voice, and gestures. Marked indifference or flatness even when discussing distressing topics. In the case of euphoric or dysphoric individuals, rate Blunted Affect if a flat quality is also clearly present.

0. Not Assessed.

1. Not Present.

2. Very Mild. Emotional range is slightly subdued or reserved but displays appropriate facial expressions and tone of voice that are within normal limits.

3. Mild. Emotional range overall is diminished, subdued or reserved, without many spontaneous and appropriate emotional responses. Voice tone is slightly monotonous.

4. Moderate. Emotional range is noticeably diminished, individual doesn’t show emotion, smile or react to distressing topics except infrequently. Voice tone is monotonous or there is noticeable decrease in spontaneous movements. Displays of emotion or gestures are usually followed by a return to flattened affect.

5. Moderately Severe. Emotional range very diminished, individual doesn’t show emotion, smile, or react to distressing topics except minimally, few gestures, facial expression does not change very often. Voice tone is monotonous much of the time.

6. Severe. Very little emotional range or expression. Mechanical in speech and gestures most of the time. Unchanging facial expression. Voice tone is monotonous most of the time.

7. Extremely Severe. Virtually no emotional range or expressiveness, stiff movements. Voice tone is monotonous all of the time.

Prompts

• Use the following probes at end of interview to assess emotional responsivity: “Have you heard any good jokes lately? Would you like to hear a joke?”

13. Emotional Withdrawal

Deficiency in individual’s ability to relate emotionally during interview situation. Use your own feeling as to the presence of an ‘invisible barrier’ between individual and interviewer. Include withdrawal apparently due to psychotic processes.

0. Not Assessed.

1. Not Present.

2. Very Mild. Lack of emotional involvement shown by occasional failure to make reciprocal comments, appearing preoccupied, or smiling in a stilted manner, but spontaneously engages the interviewer most of the time.

3. Mild. Lack of emotional involvement shown by noticeable failure to make reciprocal comments, appearing preoccupied, or lacking in warmth, but responds to interviewer when approached.

4. Moderate. Emotional contact not present much of the interview because individual does not elaborate responses, fails to make eye contact, doesn’t seem to care if interviewer is listening, or may be preoccupied with psychotic material.

5. Moderately Severe. Same as 4 but emotional contact not present most of the interview.

6. Severe. Actively avoids emotional participation. Frequently unresponsive or responds with yes/no answers (not solely due to persecutory delusions). Responds with only minimal affect.

7. Extremely Severe. Consistently avoids emotional participation. Unresponsive or responds with yes/no answers (not solely due to persecutory delusions). May leave during interview or just not respond at all.

14. Motor Retardation

Reduction in energy level evidenced by slowed movements and speech, reduced body tone, decreased number of spontaneous body movements. Rate on the basis of observed behavior of the individual only. Do not rate on the basis of individual’s subjective impression of his own energy level. Rate regardless of medication effects.

0. Not Assessed.

1. Not Present.

2. Very Mild. Slightly slowed or reduced movements or speech compared to most people.

3. Mild. Noticeably slowed or reduced movements or speech compared to most people.

4. Moderate. Large reduction or slowness in movements or speech.

5. Moderately Severe. Seldom moves or speaks spontaneously OR very mechanical or stiff movements

6. Severe. Does not move or speak unless prodded or urged.

7. Extremely Severe. Frozen, catatonic.

15. Tension

Observable physical and motor manifestations of tension, ‘nervousness’ and agitation. Self-reported experiences of tension should be rated under the item on anxiety. Do not rate if restlessness is solely akathisia, but do rate if akathisia is exacerbated by tension.

0. Not Assessed.

1. Not Present.

2. Very Mild. More fidgety than most but within normal range. A few transient signs of tension, e.g., picking at fingernails, foot wagging, scratching scalp several times or finger tapping.

3. Mild. Same as 2, but with more frequent or exaggerated signs of tension.

4. Moderate. Many and frequent signs of motor tension with one or more signs sometimes occurring simultaneously, e.g., wagging one’s foot while wringing hands together. There are times when no signs of tension are present.

5. Moderately Severe. Many and frequent signs of motor tension with one or more signs often occurring simultaneously. There are still rare times when no signs of tension are present.

6. Severe. Same as 5, but signs of tension are continuous.

7. Extremely Severe. Multiple motor manifestations of tension are continuously present, e.g., continuous pacing and hand wringing.

16. Uncooperativeness

Resistance and lack of willingness to co-operate with the interview. The uncooperativeness might result from suspiciousness. Rate only uncooperativeness in relation to the interview, not behaviors involving peers and relatives.

0. Not Assessed.

1. Not Present.

2. Very Mild. Shows non-verbal signs of reluctance, but does not complain or argue.

3. Mild. Gripes or tries to avoid complying, but goes ahead without argument.

4. Moderate. Verbally resists but eventually complies after questions are rephrased or repeated.

5. Moderately Severe. Same as 4, but some information necessary for accurate ratings is withheld.

6. Severe. Refuses to co-operate with interview, but remains in interview situation.

7. Extremely Severe. Same as 6, with active efforts to escape the interview.

17. Excitement

Heightened emotional tone or increased emotional reactivity to interviewer or topics being discussed, as evidenced by increased intensity of facial expressions, voice tone, expressive gestures or increase in speech quantity and speed.

0. Not Assessed.

1. Not Present.

2. Very Mild. Subtle and fleeting or questionable increase in emotional intensity. For example, at times seems keyed-up or overly alert.

3. Mild. Subtle but persistent increase in emotional intensity. For example, lively use of gestures and variation in voice tone.

4. Moderate. Definite but occasional increase in emotional intensity. For example, reacts to interviewer or topics that are discussed with noticeable emotional intensity. Some pressured speech.

5. Moderately Severe. Definite and persistent increase in emotional intensity. For example, reacts to many stimuli, whether relevant or not, with considerable emotional intensity. Frequent pressured speech.

6. Severe. Marked increase in emotional intensity. For example, reacts to most stimuli with inappropriate emotional intensity. Has difficulty settling down or staying on task. Often restless, impulsive, or speech is often pressured.

7. Extremely Severe. Marked and persistent increase in emotional intensity. Reacts to all stimuli with inappropriate intensity, impulsiveness. Cannot settle down or stay on task. Very restless and impulsive most of the time. Constant pressured speech.

18. Mannerisms and Posturing

Unusual and bizarre behavior, stylized movements or acts, or any postures which are clearly uncomfortable or inappropriate. Exclude obvious manifestations of medication side effects. Do not include nervous mannerisms that are not odd or unusual.

0. Not Assessed.

1. Not Present.

2. Very Mild. Eccentric or odd mannerisms or activity that ordinary persons would have difficulty explaining, e.g., grimacing, picking. Observed once for a brief period.

3. Mild. Same as 2, but occurring on two occasions of brief duration.

4. Moderate. Mannerisms or posturing, e.g., stylized movements or acts, rocking, nodding, rubbing, or grimacing, observed on several occasions for brief periods or infrequently but very odd. For example, uncomfortable posture maintained for 5 seconds more than twice.

5. Moderately Severe. Same as 4, but occurring often, or several examples of very odd mannerisms or posturing that are idiosyncratic to the individual.

6. Severe. Frequent stereotyped behavior assumes and maintains uncomfortable or inappropriate postures, intense rocking, smearing, strange rituals or fetal posturing. Individual can interact with people and the environment for brief periods despite these behaviors.

7. Extremely Severe. Same as six, but individual cannot interact with people or the environment due to these behaviors.

Brief Psychiatric Rating Scale (BPRS)

Patient Name: Today’s Date:

Please enter the score for the term that best describes the patient’s condition.

0 = Not assessed, 1 = Not present, 2 = Very mild, 3 = Mild, 4 = Moderate, 5 = Moderately severe,
6 = Severe, 7 = Extremely severe

Score
		SOMATIC CONCERN Preoccupation with physical health, fear of physical illness, hypochondriasis.
		ANXIETY Worry, fear, over-concern for present or future, uneasiness.
		EMOTIONAL WITHDRAWAL Lack of spontaneous interaction, isolation deficiency in relating to others.
		CONCEPTUAL DISORGANIZATION Thought processes confused, disconnected, disorganized, disrupted.
		GUILT FEELINGS Self-blame, shame, remorse for past behavior.
		TENSION Physical and motor manifestations of nervousness, over-activation.
		MANNERISMS AND POSTURING Peculiar, bizarre, unnatural motor behavior (not including tic).
		GRANDIOSITY Exaggerated self-opinion, arrogance, conviction of unusual power or abilities.
		DEPRESSIVE MOOD Sorrow, sadness, despondency, pessimism.
		HOSTILITY Animosity, contempt, belligerence, disdain for others.
		SUSPICIOUSNESS Mistrust, belief others harbor malicious or discriminatory intent.
		HALLUCINATORY BEHAVIOR Perceptions without normal external stimulus correspondence.
		MOTOR RETARDATION Slowed, weakened movements or speech, reduced body tone.
		UNCOOPERATIVENESS Resistance, guardedness, rejection of authority.
		UNUSUAL THOUGHT CONTENT Unusual, odd, strange, bizarre thought content.
		BLUNTED AFFECT Reduced emotional tone, reduction in formal intensity of feelings, flatness.
		EXCITEMENT Heightened emotional tone, agitation, increased reactivity.
		DISORIENTATION Confusion or lack of proper association for person, place or time.

MIRECC GAF Occupational Scale and Anchors

Occupational Scale

For the occupational scale, enter score based on the participant’s primary role during this period – Worker, Student, or Homemaker.

Enter score using the scale corresponding to the participants “primary role” (i.e., Worker, Student, or Homemaker)

Assign scores based on participant’s average level of functioning during the month prior to the date of administration of the scale.

A few additional notes:

* Competitive work includes jobs paying at least minimum wage and for which anyone in the community can apply. Off-the-books work can also be considered competitive, as long as the worker is paid at least minimum wage. If a person works for a family member or a close friend, consider the extent to which the person’s position is protected or limited by those family or friend relationships when deciding whether those jobs are competitive. Jobs set aside for people with mental illness or other disabilities are not considered competitive work.

** Non-competitive work includes work in sheltered workshops or jobs completed with family members or close friends only. If person is working for a family member or friends, consider the extent to which individual’s position is limited or protected by these relationships.

*** Rate lower within the decile if the individual has accommodations or a modified schedule. For students on summer vacation or enrolled for the fall, score based on most recent academic performance, and rate up or down in decile on the basis of other activities and responsibilities.

**** This does not apply to individuals who could be in the labor force or who would be expected to be a student as their primary role; score these individuals using the Worker or Student columns, respectively.

Date (MM/DD/YYYY):

Worker

Worker: Occupational Scale
Fully Functional
90-100	Working competitively* and excelling in the workplace (e.g., getting promotions; highly valued by supervisors, etc.).
80-89	Working competitively* and doing well at work but not excelling.
70-79	Working competitively* and having minor difficulties at work; occasional problems with attendance, performance, or work relations.
Borderline Functional
60-69	Consider need for additional supports, such as from a vocational program.	Working competitively* with moderate impairment in performance or work relations; or has moderate problems with attendance or working the scheduled number of hours.
50-59		Working competitively* with significant impairment in performance or work relations; or has significant problems with attendance or working the scheduled number of hours.
Dysfunctional
40-49	Consider other activities, or contributions to household such as housework and childcare, or managing some kind of income (e.g. allowance, SSI/SSDI checks).	Working a considerable number of hours in a non-competitive work setting.** Also performing at least one other activity (see sidebar to the left).
30-39		Working some hours in a non-competitive work setting** with minimal participation in other activities.
20-29		No work activities. Score higher within range if other activities accomplished.
Dangerousness
10-19	Not able to obtain 1-2 of the following: food, shelter, clothing, and basic hygiene.
1-9	Not able to obtain 3-4 of the following: food, shelter, clothing, and basic hygiene.
0	No information available.

Date (MM/DD/YYYY):

Student

Student: Occupational Scale
Fully Functional
90-100	Performance in school: Consider grades; difficulty and number of classes; ability to meet class requirements in a timely manner; need for academic supports beyond norm in community. Participation in school-based or extra-curricular activities: Consider level of involvement and difficulty. School attendance should be consistent.	Very high level of functioning with excellent grades and challenging array of activities.
80-89		High level of functioning with good grades and average array of activities.
70-79		Satisfactory level of functioning with some minor difficulties maintaining school program.
Borderline Functional
60-69	Performance in school: Significantly lower than expected (e.g., lower grades, reduced class load, missed assignments and need for extensions, and/or need for extra supports). Participation in school-based or extra-curricular activities: Extra-curricular activities markedly reduced, performed with impairment, or eliminated. School attendance sometimes inconsistent, with some negative consequences. Score lower in the range for a greater number of problems and for greater severity.	For 60-69, must be passing all classes with grades above D. Score within upper end of range (65-69) if moderate problems in one area.
50-59		In school with significant impairment in academic performance; or has significant problems with attendance or extra-curricular activities
Dysfunctional
40-49	Performance in school: Not necessarily failing, but preponderance of very poor grades. May have limited attendance. May require extensive assistance.
30-39	Attends school OCCASIONALLY but failing most or all classes.
20-29	Not attending school at all or attending school and failing all classes.
Dangerousness
10-19	Not able to obtain 1-2 of the following: food, shelter, clothing, and basic hygiene.
1-9	Not able to obtain 3-4 of the following: food, shelter, clothing, and basic hygiene.
0	No information available.

Date (MM/DD/YYYY):

Homemaker

Homemaker / Not in Labor Force: Occupational Scale
Fully Functional
90-100	Keeps home orderly and clean, completes household tasks, and cares for children consistently (no untreated injuries/illnesses; children properly supervised and provided appropriate meals and clothing).	Requires no assistance and completes all tasks in an exceptional manner.
80-89		Requires little assistance and completes most tasks well.
70-79		Completes tasks at an acceptable level but has some minor difficulties.
Borderline Functional
60-69	Requires regular assistance with some cleaning, household or child care duties. Without such help, keeps home somewhat untidy, only partially completes household tasks, and cares for children inconsistently (no untreated injuries/illnesses but preventive medical/dental care can be improved; meals are sometimes nutritionally unbalanced or skipped; children have few clean clothes; children are bathed when dirty rather than regularly; supervision outside of home is provided, but sometimes supervision inside the home is lacking). Score lower in the range for greater number of problems and for increased assistance needed.	Score within upper end of range (65-69) if only minor problems in one area.
50-59		Score within lower end of range (50-55) if moderate problems in all three areas, including tidiness, other household tasks, and childcare; or severe problems in one area.
Dysfunctional
40-49	Requires extensive help with childcare, home cleaning and household duties. Without help, home is untidy, ranging from lots of dust, dirty dishes, and trash piled in rooms; to vermin or pest infestation, smells of mildew, and home layered with dirt, debris, or food waste. Without help, care for children is inadequate (inadequate medical attention, meals provided about once a day or less; children are lacking 1-2 basic items of clothing or some essential items are in very poor condition; inappropriate or no supervision). Score lower in the range for greater number of problems and for increased assistance needed.	Severe difficulty and need for help in one area (score within lower end of range for inadequate performance as the severity and number of problems increase).
30-39		Makes contributions to two or three of these areas, but generally needs significant help.
20-29		Makes minor contributions to one or two of the three areas, but generally needs significant help.
Dangerousness
10-19	Not able to obtain 1-2 of the following: food, shelter, clothing, and basic hygiene.
1-9	Not able to obtain 3-4 of the following: food, shelter, clothing, and basic hygiene.
0	No information available.

MIRECC GAF Social Functioning Scale and Anchors

Social Functioning

Assign score based on participant’s average level of functioning during the month prior to administration of the tool.

• Both friends and family should be considered in this rating.

• Rating should take into account the number of relationships, the meaningfulness of these relationships (frequency of contact and ability to confide in one another), and ability to develop new relationships.

• Consider frequency of conflict, how conflict is resolved, and presence of social avoidance or withdrawal.

• Individuals with no meaningful relationships should be rated no higher than the dysfunctional range.

• Do not consider relationships with professional caregivers when rating in the Borderline Functional and Fully Functional ranges, but do consider interactions with professional caregivers when making ratings in the Dysfunctional and Dangerousness ranges.

Social Functioning Scale

Social
Fully Functional
90-100	Superior functioning: Many meaningful interpersonal relationships; skilled at developing new relationships.
80-89	Socially effective: At least three meaningful interpersonal relationships; able to develop new meaningful relationships.
70-79	Slight impairment: At least two meaningful interpersonal relationships, or relationships limited to people in family or household; some difficulty in developing new meaningful relationships; low levels of difficulty with interpersonal conflict or avoidance.
Borderline Functional
60-69	At least one meaningful interpersonal relationship, but appreciable difficulty with interpersonal conflict or avoidance.
50-59	Able to maintain at least one meaningful interpersonal relationship, but frequent difficulty (most days) with interpersonal conflicts or withdrawal.
Dysfunctional
40-49	No meaningful interpersonal relationships, but connects to others in the course of ordinary daily life without conflict or difficulty; able to have conversations and/or participate in group activities.
30-39	No meaningful interpersonal relationships, as well as intermittent difficulty in relating to others in the course of ordinary daily life, sustaining conversations, and/or participating in group activities.
20-29	No meaningful interpersonal relationships, as well as regular difficulty in relating to others in the course of ordinary daily life, sustaining conversations, and/or participating in group activities.
Dangerousness
10-19	No meaningful interpersonal relationships, selectively dysfunctional connections to others [actively avoids and/or pushes some people away].
1-9	No meaningful interpersonal relationships, grossly dysfunctional connections to others [actively avoids and/or pushes most people away]. Only able to interact with people for brief periods of time.
0	No information available.

MIRECC GAF Symptom Scale and Anchors

Symptom Scale

Assign score based on participant’s worst level of functioning during the month prior to the date that the measure is administered.

Date (MM/DD/YYYY):

Symptoms
Fully Functional
90-100	None
80-89	Very minimal
70-79	Symptoms in reaction to stressors (1 to 2 days maximum)
Borderline Functional
60-69	Mild (e.g. persistent and mildly depressed mood, minimal or no ongoing disability)
50-59	Moderate (e.g., moderate depression, occasional panic attacks, flat affect, circumstantial speech)
Dysfunctional
40-49	Serious (e.g., suicidal thoughts, severe obsessions or persistent anxiety, frequently intoxicated)
30-39	Impairment in reality testing or communication (e.g., delusions, intrusive hallucinations, speech that is at times illogical, irrelevant, or obscure)
20-29	Behavior is influenced by delusions or hallucinations; serious impairment in communication (at times incoherent) or judgment; suicidal preoccupation
Dangerousness
10-19	Some dangerousness to self or others (e.g., suicidal “gestures,” violence, manic excitement); gross communication impairment (incoherent or mute)
1-9	Persistent and imminent danger to self or others
0	No Information available

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