This was one of the most difficult reports I did. It didn't help that you did this type of report one time in the whole course.
And as always- Use these notes to help you on your journey.

REASON FOR REFERRAL
Masters Degree not capitalized because it isn't a specific degree
No comma after refusing to leave

HISTORY OF PRESENT ILLNESS

Weston Hospital twice ( no comma here)
Both Orange harbor Hospital and Weston Hospital are capitalized

PHYSICAL EXAMINATION
appearance, wet,

ASSESSMENT
Axis V Global Assessment of function scale: 15. Six-month projection 40. Twelve-month projection 40. Past year 60.