Report Template

PSYCHOLOGICAL EVALUATION
(Confidential)
Name Align demographic data here
!ate of "irt# *
A$e *
Referred %& *
P'&(#olo$i't *
Pla(e of E)amination *
!ate of E)amination *
!ate of Report *
E)aminer *
Rea'on for Referral
(Typically, to clarify diagnosis, to assist in differential diagnosis, to assist in treatment
planning, to answer a particular question or set of questions. Before beginning any
assessment, clarify the questions to be answered by the assessment. Include the client's
questions, as well as those of third parties. The clearer the reason for the assessment is,
the more helpful you can be to the client.
Pro(ed*re' (!ist any procedures completed, in order of administration. In the standard
battery, the order gi"en below is the typical, #peel the onion$ order. %or &ogniti"e
Assessment, include as #&linical Inter"iew$ the collection of bac'ground information.
The standard battery consists of those tests mar'ed with a *.
&linical Inter"iew*
(echsler Adult Intelligence )cale *III ((AI)*III* or
(echsler Intelligence )cale for &hildren + I, ((I)&*I,*
Bender*-estalt Test*
.ouse*Tree*/erson*
Incomplete )entences Blan'*
0innesota 0ultiphasic /ersonality In"entory *1 (00/I*1*
Thematic Apperception Test (TAT*
2orschach In'blot 0ethod*
!ife )tyle In"entory
3thers as needed to answer the referral question
"a(+$ro*nd Information
Identify the sources of information, and an assessment of their reliability as sources.
Include here information regarding the following topics4 Identifying information
including age, gender, ethnocultural identity, marital status, and occupation or academic
role. /rior psychological assessment. /resenting complaint and symptoms. .istory of
the presenting complaint including onset, duration, course (times when it5s better or
worse, prior treatment efforts and success of these, client's conceptuali6ation of the
problem. 3ther personal, academic, wor', medical, social, or family history rele"ant to
the referral question, presenting complaints, or diagnoses under consideration. 3ther
psychological7 psychiatric problems in the family history. (8ote4 9o not name family
members. 2efer to them by relationship only. :.g., Mr. Xs uncle "ersus, John Smith,
Mr. Xs uncle; older brother "ersus Tom Smith, Mr. Xs older brother.
Also include4 reports of substance abuse4 what, how recently, how often, how long.
0edication use4 what medication, dose, when last dose was ta'en, what it is for.
"e#a,ioral O%'er,ation'
This section should describe what the client brings to the testing. They represent your
clinical obser"ations apart from the test situation itself. These are not diagnostic
conclusions. <eep it descripti"e, not e"aluati"e or conclusi"e. This section also does not
include the client's response to specific test stimuli. That belongs under =results=. To
clarify, The client became increasingly anxious as testing progressed, and refused to
complete the rithmetic subtest does belong here, as it describes the client5s an>ious
state. The client laughed upon being presented !ith set " of the #icture rrangement
subtest, saying it reminded her of her mother does not belong here (if, indeed, it is
useful at all? because it is a response to a specific test item. In addition, The client
appeared to be using a sensory approach to Matrix $easoning, belongs under test
results because it indicates not a state, but an approach to the particular tas'. %inally,
The client appeared to be suffering from a generali%ed anxiety, is a diagnostic
conclusion, and belongs at the end of the report, after test results (the data that informs
the conclusion ha"e been presented.
93 include here the following4 )etting constraints on testing (e.g., two or more sessions,
interference, etc.. 0ental )tatus information, including appearance if noteworthy or
related to referral question. 3rientation to person, place and time, especially in settings
where that might be in question, such as psychiatric, forensic, or rehabilitation7
neurological settings. Ideation e"ident in beha"ior, such as suicidal7 homicidal
comments, e"idence of delusional or hallucinatory thin'ing e"ident in beha"ior (as
opposed to e"ident in test results. )peech quality, e.g., intonation, modulation, pressure,
fluidity, speech problems. Apparent mood (that is, affect during testing. .andicaps4
glasses or contacts (to correct what@, hearing aid, gait or motor problems, hand tremors,
etc. &ooperation, persistence, effort.
0a'e a statement here about the "alidity of results based on beha"ioral obser"ations and
history. %or e>ample, you could say, &'ased on Mr. X(s beha)ior, and his apparent effort
and cooperation, test results are li*ely to +be an accurate assessment of, underestimate
his (typical functioning, functioning at this time, or potential=.
8ote the parentheses. They suggest alternati"es. 8ote especially the last set. #Typical
functioning$ means you thin' this is the way the client functions generally, and that the
test results are not unduly influenced by situational factors. #&urrent functioning$ means
this is the way the client is functioning 83(, but the results may not indicate prior
functioning or predict future functioning. This is appropriate when, for e>ample, you are
testing a person who is reco"ering from brain inAury, or who is se"erely depressed.
#/otential$ indicates you are trying to predict how the person will function in the future,
such as on the Aob, or in school. %or e>ample, you might be e"aluating a student for
special ser"ices, and the test results may reflect about how well the student can be
e>pected to perform at his7her best (pro"ided you were able to moti"ate the student to
perform well, and there were no situational or personal constraints.
)ome e>amples4
'ased upon Johnnys ob)ious cooperation, persistence, and effort, these tests results are
li*ely to accurately reflect his true potential.
'ased upon Johnnys lac* of cooperation and difficulty !ith concentration and
persistence, these results li*ely underestimate his true potential. ,o!e)er, they may
accurately reflect his functioning under the current stress of family disruption.
'ased upon Mrs. Smiths effort, concentration, and cooperation, these results li*ely
accurately reflect her current depressed functioning.
'ased upon the number of interruptions and the less than optimal testing conditions,
these results li*ely underestimate Ms. Jones true score, despite her cooperation, effort,
and ob)ious desire to succeed.
These test results may slightly o)erestimate Mr. Smiths true score, particularly on
#erformance tas*s, due to his familiarity !ith the test materials.
Mr. Smiths history, and his cooperation !ith the testing procedure, suggest that the
results reflect his typical functioning.
Co$niti,e -*n(tionin$
(Select appropriate phrases. -ote. here and throughout, underlines are space holders.
/o not use underlining in the report itself.0
(0r.70rs.70s. B's performance on the (AI)*C places him7her within the (a"erage7
abo"e a"erage7 superior7 borderline7 e>tremely low range of intellectual functioning.
(.is7.er %ull )cale ID of EEE is higher than that of EEEEF of indi"iduals (his7her age.
(T#i' la't 'tati'ti( i' (alled a per(entile ran+. !on/t (onf*'e it 0it# %ein$ 1234 '*re
of &o*r re'*lt'5) An ID of GH to IIH is a"erage. (ere (s7he tested again under similar
circumstances; there is a GJF chance that (his7her score would fall between EEE and
EEE. (T#e la't p#ra'e i' t#e 1(onfiden(e inter,al.5 Yo* are 234 confident t#at t#e
per'on/' 1tr*e '(ore5 fall' 0it#in t#e $i,en interval of '(ore'. -ollo0 t#at pattern in
reportin$ VI6 and PI6 '(ore'7 %*t a%%re,iate it a' follo0'.) 0r.70rs.70s. B earned a
,ID of EEE (E*EF, EEE*EEEE, and a /ID of EEE (E*EF, EEEE*EEEE. (T#e 8 i' t#e
per(entile ran+ for t#e '(ore.)
The EE point difference between (0r.70rs.70s's ,ID and /ID (is7is not significant.
(Remem%er t#at if it i' not 'tati'ti(all& 'i$nifi(ant7 it i' not li+el& to %e (lini(all&
'i$nifi(ant7 *nder mo't (ir(*m'tan(e'. T#at mean' if t#e differen(e i' too 'mall to
dete(t 0it# pre(i'e 'tati'ti('7 it i' *nli+el& to %e dete(ta%le %& t#e na+ed e&e7 and
t#*' #a,e an& meanin$ in de'(ri%in$ t#e per'on/' %e#a,ior. T#erefore7 if t#ere i' no
'tati'ti(al differen(e7 &o* treat t#e '(ore' a' identi(al. In addition7 t#ere i' no '*(#
t#in$ a' 1almo't5 'tati'ti(all& 'i$nifi(ant. It eit#er i' or i' not. So7 do not interpret
a' *'ef*l7 di'tin$*i'#in$7 or rele,ant a differen(e t#at approa(#e' %*t doe' not e9*al
or '*rpa'' t#e (*t off for 'i$nifi(an(e:) 8e>t, discuss implications of the difference, if
an& e)i't'.
The (AI)*III also yields the following Inde> )cores and subtest scales scores. Inde>
scores of GH to IIH and scaled scores of K to I1 are a"erage. (0r.70rs.70s. B obtained
the following scores.
S(ore 4ile Ran$e S(ore 4ile Ran$e
Ver%al
Compre#en'ion
;;; ;; ;;<;; Per(ept*al
Or$ani=ation
;;; ;; ;;
,ocabulary EE /icture &ompletion EE
)imilarities EE Bloc' 9esign EE
Information EE 0atri> 2easoning EE
&omprehension EE /icture Arrangement EE
3bAect Assembly EE
>or+in$
?emor&
;;; ;; ;; Pro(e''in$ Speed ;;; ;; ;;
Arithmetic EE 9igit*)ymbol7&oding 11
9igit )pan EE )ymbol )earch 11
!etter*8umber
)equencing
EE
The %)ID accurately reflects the person5s o"erall ID only insofar as it reflects a unified
construct. If ,ID and /ID are significantly di"ergent, the meaning of the %)ID is in
doubt. )imilarly, ,ID and /ID are useful constructs only if their component inde> scores
are comparable. (In the ne>t iteration of the (AI), ,ID and /ID will be eliminated.
,&I and /3I are more pure measures of "erbal and "isual*motor functioning. &ompare
these as you would ,ID and /ID.
(or'ing down the hierarchy, each inde> score is meaningful as a construct only if the
subtests that ma'e up that measure #hang together$ statistically. 9iscuss meaning of B's
scores and their comparisons from the discrepancy analysis page of the (AI)*III record
form using that hierarchy. 9iscuss both which scores are statistically high, low or
a"erage compared to the general population (nomothetic comparison, and which scores
are strengths or wea'nesses when compared to the client5s o"erall functioning
(idiographic comparison. (hen discussing (or'ing 0emory, discuss the meaning of
9igits %orward and 9igits Bac'ward, if significant or rele"ant. Address the assessment
of incidental memory from 9igit )ymbol * and the recall portion of Bender. 9ifferentiate
poor performance on &oding due to motor "s. incidental memory.
At the bottom of the hierarchy, each subtest accurately assesses performance on its
construct to the e>tent that intra*subtest scatter is minimal. 9iscuss any scatter. !oo' for
patterns in #hits and misses.$ :.g., does the person miss all geography questions on the
Information subtest@ All di"ision problems on Arithmetic@ 9iscuss the implications of
any such patterns.
Contin*e &o*r report %& di'(*''in$ t#e re'*lt' of an& ot#er a(#ie,ement or (o$niti,e
te'tin$. T#ere are more *'ef*l < and le'' *'ef*l < 0a&' to pre'ent a(#ie,ement te't
re'*lt'. If &o* are admini'terin$ t#e'e7 (ome tal+ 0it# me7 and I/ll #elp &o* identif&
met#od' t#at #i$#li$#t *nderl&in$ (o$niti,e pro(e''e'. 9iscuss the implications of
such results. &ompare with (AI)*III results, and discuss the implications of the
differences. 9o not diagnose specific learning disability from ability and achie"ement
test comparisons alone, but point to what the differences suggest, including whether
additional assessment is needed. Bear in mind that learning disability assessment
requires both an ability*achie"ement discrepancy and deficits in some underlying
cogniti"e process. /ay attention, therefore, to the underlying processes assessed in all
instruments, as, for e>ample, the inde> scores on the (echsler.
Include rele"ant findings from the 0):, Bender, .ouse*Tree*/erson, and )entence
&ompletion, TAT, 2orschach, etc. (8eurologically intact or not according to <oppit65s
and7or !ac's5 criteria, construction comple>ity on .T/ and7or results of 9A/ scoring of
person drawing; presence of cogniti"e, motor, or perceptual problems on the Bender,
.T/; number and comple>ity of responses on the 2orschach; "ocabulary usage, fluency
of language, e"idence of learning disabilities or higher intelligence in content, grammar,
spelling, punctuation, etc.
2esol"e any discrepancies in the data by identifying the differences or similarities in the
constructs being measured, setting or client characteristics, or tas' demands. %or
e>ample, memory tested using sentence recall, digit recall, 'inesthetic recall, and "isual
recall may differ, as may free recall "ersus cued recall. (:.g., do you prefer multiple
choice, or fill*in*the*blan' tests@
8ote unusual beha"ioral responses to test stimuli, or to the testing situation itself,
particularly unusual responses. Alternately, note normal responses when the unusual
would be e>pected. %or e>ample, an allegedly hyperacti"e child attends, persists,
concentrates, and so forth (might be effect of medication, misdiagnosis, orL 9escribe
any information gained or performance differences obser"ed from testing the limits (and
describe the method of testing of the limits?.
Try to translate all of this into general terms. (hat do strengths and wea'nesses in the
abo"e areas loo' li'e in this person5s e"eryday life@ .ow are they connected to the
presenting problem or other reason for referral@
)um up this section by discussing the implications of the results. (hat do they say about
the client5s o"erall cogniti"e functioning and cogniti"e style@
So(ial<Emotional -*n(tionin$
9iscuss the implications of the person's cogniti"e strengths, wea'nesses, and style for
daily functioning. Address the person's capacity to appreciate reality and control
irrationality, his7her Audgment and empathic ability.
Identify the person's primary psychological symptoms, if any. (hat is the nature of the
person's an>iety@ Mnder what circumstances does the person manifest an>iety@ .ow is
the an>iety manifested@ .ow does the person attempt to cope with an>iety, stress, and
the current situation@ .ow effecti"e are these methods for him7her@ 9iscuss the person's
capacity for appropriate (not too la>, not too harsh impulse control.
Identify the person's predominant affect and mood. 9iscuss the person5s degree of
responsi"eness to affecti"e stimuli, his7her range of affect, and its appropriateness to the
situation.
Identify the cogniti"e, social*emotional, situational (and biological, if applicable factors
that underlie the presenting problem, if any, or that relate to the referral question.
2elate the abo"e to the person's lifestyle, presenting problems, and social, academic7
occupational, interpersonal, and family functioning. Identify the person's "iew of self,
world, others, future. 2elate these to the life tas's of wor', lo"e, community7friendship
(and self and spirituality. (hat are the core beliefs that affect the person5s functioning,
especially those rele"ant to the referral question@
Identify the areas in which the person demonstrates psychological strength and positi"e
qualities. 2elate these to the presenting problem and7or referral question.
S*mmar&
"riefl& summari6e the report as a whole. )ome audiences (Audges, busy psychiatrists
read only the summary, so you must be succinct, clear, and direct. )tart with a
generali6ed mention of intelligence testing results, gi"ing the le"el of intelligence, and
any noteworthy strengths, wea'nesses, or stylistic patterns obser"ed. Then summari6e
o"erall personality assessment results, highlighting the more central and salient aspects of
the person5s #ality$ and his7her current functioning.
&learly and simply relate the results to the referral question, and A8)(:2 T.:
DM:)TI38 in as straightforward and clear a manner as possible. 0a'e sure your
answer is clearly supported by the test data. -i"e 0M&. more weight to the data and to
actuarial interpretation of results than to your #clinical impressions.$ (here there is
conflict between clinical impression and data, say so, and identify which is which.
NOTE Information and hypotheses listed in the summary should reflect /2:,I3M)!N
9I)&M)):9 information and hypotheses. 8o new information or hypotheses should be
presented here.
Again, &!:A2!N A8)(:2 the referral question.
!ia$no'i' 8ote that for some referral questions, diagnosis is not the issue, and no
diagnosis should be gi"en. %or e>ample, pre*employment screening does not require a
diagnosis. %or purposes of the assessment sequence and qualifying e>ams, full, J*a>is
diagnoses must be gi"en.
A>is I4 BBB.BB ((rite out diagnosis and modifiers for A>es I and II
A>is II4 BBB.BB in addition to their codes.
A>is III4 (0edical conditions that impact on the referral question, if any. 8ote the
source of the information, such as medical file, patient report, or client5s
physician, or #per 9)0*I, criteria$. %ailure to cite the source can lea"e you
open to charges of practicing medicine without a license, because you are not
qualified to ma'e medical diagnoses.
A>is I,4 (/sychosocial stressors4 list specific stressors, and identify them as mild,
moderate, se"ere or e>treme. 8ote that the rating is by obAecti"e criteria.
AdAusting to a new school is usually a mild stressor, but may become moderate is
preceded by a mo"e at a "ulnerable age or by a complication such as coping with
peer reaction to a physical disability, or may be more se"ere if it comes as a result
of some trauma.
A>is ,4 -A% &urrent4 EE
-A% .ighest in past year4 EE
(8ote that a person5s current le"el of adapti"e functioning cannot e>ceed his7her
highest le"el of functioning in the past year, since the day you assessed him7her is
a part of the past year?
Re(ommendation' (Mse whiche"er apply of those below, and7or additional or
alternati"e ones pertinent to the referral question.
I. Identify whether psychological treatment is warranted. If so, related to what
specific issues@ (hat mode@ (hat 'ind@ (hat frequency, intensity, setting, and
urgency@ To achie"e what goals@ 3f what e>pected duration@
:>ample4
2ontinued inpatient hospitali%ation is !arranted due to Mr. Smiths suicidal ideation
and plan, concurrent se)ere anxiety and lac* of social support.
3ndi)idual, outpatient, cogniti)e4beha)ioral therapy, once !ee*ly, to address Ms. Jones
ad5ustment to college and separation anxiety is recommended. Ms. Jones should begin
!or*ing !ith the college counselor this !ee* if possible, as she is considering
terminating her enrollment and returning home.
Ms. Smith should be referred to 6inheart for participation in coming out groups to
help her identify and cope !ith the issues related to her decision to re)eal her sexual
orientation to her family, and to recei)e support from others after ha)ing been outed at
!or*.
1. &onsider medical e"aluation@ To alle"iate what symptoms@
:>ample4
3f Ms. Jones anxiety does not abate !ithin t!o !ee*s, the 2ampus ,ealth 2are 2enter
should schedule Ms. Jones for a medical e)aluation to determine !hether antianxiety
mediation is needed. Specific attention should be paid to e)aluating her sleep pattern at
that time, as she reports sleep depri)ation due to excessi)e !orry at night.
C. %urther assessment@ (hat 'ind@ By whom (what specialty@ To resol"e what
questions@
:>ample4
-europsychological assessment is recommended to assess the extent and nature of
brain damage Mr. Smith has suffered as a result of his substance abuse. $ehabilitation
e)aluation is recommended to identify inter)entions that may help him cope !ith his
impairments.
O. 8on*psychological, non*psychiatric inter"entions needed@ (hat 'ind@ By whom@
3ther agencies need to be in"ol"ed@
:>ample4
7i)en the nature of Mrs. Smiths cultural and religious beliefs, and their impact on her
!illingness to see* therapy, consultation !ith and8or referral to her rabbi is
recommended. This consultation should identify !hether the rabbi is capable of helping
Mrs. Smith !ith her depression, or !hether the rabbi can assist her in accepting the
professional help she clearly needs.
J. :n"ironmental inter"entions needed@
:>ample4
Johnny needs to be seated at the front of each classroom, so that he is able to see the
board.
This employee should be s!itched to a position that minimi%es interaction !ith
customers, and pro)ides him !ith opportunity to sociali%e !ith a small cadre of fello!
!or*ers.
P. Issues that might interfere with treatment and how to address them@
:>ample4
Ms. Jones parents see her as a )ictim of the uni)ersitys impersonal, uncaring
en)ironment. They repeatedly sympathi%e !ith and encourage Ms Jones distress.
9nless the parents can be helped to adopt a supporti)e yet adapti)e approach, this
student may fail in her transition to college. 3t is recommended that the /ean of Students
arrange to meet !ith the parents and that they be referred to the #arents4in4Transition
outreach program.
-inall&7 in(l*de a formal 'i$nat*re %lo(+7 0#i(# loo+' li+e t#i'
2espectfully submitted,
EEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEE EEEEEEEEEEEEEEEEEEEEEEEE
Nour name, highest :A28:9 and 2:!:,A8T degree 9r. %irst !ast
:>aminer (or /sychology Intern )uper"isor
Et#i(al $*ideline' 'pe(if& t#at &o* '#o*ld li't onl& &o*r #i$#e't de$ree (or t0o if
rele,ant7 '*(# a' @.!.7 P'&.!. if &o* pra(ti(e mental #ealt# la0). This means that your
/h.9. in economics, :nglish, or e"en education (unless it5s school psychology are not to
be listed. :"en your 0.9. or 2.8. are irrele"ant, because they did not train you to
perform psychological testing7assessment. %or purposes of your education in psychology,
you should list 38!N your 0.A. in a related mental health field.
In addition, it i' e)pre''l& pro#i%ited to li't &o*r'elf a' 1P'&.!. Candidate5.
/rofessional schools do not recogni6e or use the term. Traditionally, the term is reser"ed
for persons who ha"e completed e"erything for the doctoral degree e>cept for the
dissertation, and whose dissertation proposals ha"e been accepted. Because the path to
the /sy.9. "aries from the path to the /h.9., I)// doe' not *'e or endor'e t#e term. !o
not *'e it: