Report Template

PSYCHOLOGICAL EVALUATION
(Confidential)
Name:
Date of Birth:
Age:
Referred by:
Psychologist:
Place of Examination:
Date of Examination:
Date of Report:
Examiner:

Align demographic data here

*
*
*
*
*
*
*
*

Reason 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.)
Procedures: (List any procedures completed, in order of administration. In the standard
battery, the order given below is the typical, peel the onion order. For Cognitive
Assessment, include as Clinical Interview the collection of background information.
The standard battery consists of those tests marked with a *.)
Clinical Interview*
Wechsler Adult Intelligence Scale -III (WAIS-III)* or
Wechsler Intelligence Scale for Children IV (WISC-IV)*
Bender-Gestalt Test*
House-Tree-Person*
Incomplete Sentences Blank*
Minnesota Multiphasic Personality Inventory -2 (MMPI-2)*
Thematic Apperception Test (TAT)*
Rorschach Inkblot Method*
Life Style Inventory
Others as needed to answer the referral question
Background Information:
Identify the sources of information, and an assessment of their reliability as sources.
Include here information regarding the following topics: Identifying information
including age, gender, ethnocultural identity, marital status, and occupation or academic
role. Prior psychological assessment. Presenting complaint and symptoms. History of
the presenting complaint including onset, duration, course (times when its better or

worse), prior treatment efforts and success of these, client's conceptualization of the
problem. Other personal, academic, work, medical, social, or family history relevant to
the referral question, presenting complaints, or diagnoses under consideration. Other
psychological/ psychiatric problems in the family history. (Note: Do not name family
members. Refer to them by relationship only. E.g., Mr. Xs uncle versus, John Smith,
Mr. Xs uncle; older brother versus Tom Smith, Mr. Xs older brother.)
Also include: reports of substance abuse: what, how recently, how often, how long.
Medication use: what medication, dose, when last dose was taken, what it is for.
Behavioral Observations:
This section should describe what the client brings to the testing. They represent your
clinical observations apart from the test situation itself. These are not diagnostic
conclusions. Keep it descriptive, not evaluative or conclusive. 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 Arithmetic subtest does belong here, as it describes the clients anxious
state. The client laughed upon being presented with set 4 of the Picture Arrangement
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 Reasoning, belongs under test
results because it indicates not a state, but an approach to the particular task. Finally,
The client appeared to be suffering from a generalized anxiety, is a diagnostic
conclusion, and belongs at the end of the report, after test results (the data that informs
the conclusion) have been presented.
DO include here the following: Setting constraints on testing (e.g., two or more sessions,
interference, etc.). Mental Status information, including appearance if noteworthy or
related to referral question. Orientation to person, place and time, especially in settings
where that might be in question, such as psychiatric, forensic, or rehabilitation/
neurological settings. Ideation evident in behavior, such as suicidal/ homicidal
comments, evidence of delusional or hallucinatory thinking evident in behavior (as
opposed to evident in test results). Speech quality, e.g., intonation, modulation, pressure,
fluidity, speech problems. Apparent mood (that is, affect) during testing. Handicaps:
glasses or contacts (to correct what?), hearing aid, gait or motor problems, hand tremors,
etc. Cooperation, persistence, effort.
Make a statement here about the validity of results based on behavioral observations and
history. For example, you could say, "Based on Mr. X's behavior, and his apparent effort
and cooperation, test results are likely to (be an accurate assessment of, underestimate)
his (typical functioning, functioning at this time, or potential)".
Note the parentheses. They suggest alternatives. Note especially the last set. Typical
functioning means you think this is the way the client functions generally, and that the
test results are not unduly influenced by situational factors. Current functioning means

this is the way the client is functioning NOW, but the results may not indicate prior
functioning or predict future functioning. This is appropriate when, for example, you are
testing a person who is recovering from brain injury, or who is severely depressed.
Potential indicates you are trying to predict how the person will function in the future,
such as on the job, or in school. For example, you might be evaluating a student for
special services, and the test results may reflect about how well the student can be
expected to perform at his/her best (provided you were able to motivate the student to
perform well, and there were no situational or personal constraints).
Some examples:
Based upon Johnnys obvious cooperation, persistence, and effort, these tests results are
likely to accurately reflect his true potential.
Based upon Johnnys lack of cooperation and difficulty with concentration and
persistence, these results likely underestimate his true potential. However, they may
accurately reflect his functioning under the current stress of family disruption.
Based upon Mrs. Smiths effort, concentration, and cooperation, these results likely
accurately reflect her current depressed functioning.
Based upon the number of interruptions and the less than optimal testing conditions,
these results likely underestimate Ms. Jones true score, despite her cooperation, effort,
and obvious desire to succeed.
These test results may slightly overestimate Mr. Smiths true score, particularly on
Performance tasks, due to his familiarity with the test materials.
Mr. Smiths history, and his cooperation with the testing procedure, suggest that the
results reflect his typical functioning.
Cognitive Functioning:
(Select appropriate phrases. Note: here and throughout, underlines are space holders.
Do not use underlining in the report itself.)
(Mr./Mrs./Ms. X)'s performance on the WAIS-3 places him/her within the (average/
above average/ superior/ borderline/ extremely low) range of intellectual functioning.
(His/Her) Full Scale IQ of ___ is higher than that of ____% of individuals (his/her) age.
(This last statistic is called a percentile rank. Dont confuse it with being 95% sure
of your results) An IQ of 90 to 110 is average. Were (s/he) tested again under similar
circumstances; there is a 95% chance that (his/her) score would fall between ___ and
___. (The last phrase is the confidence interval. You are 95% confident that the
persons true score falls within the given interval of scores. Follow that pattern in
reporting VIQ and PIQ scores, but abbreviate it as follows.) Mr./Mrs./Ms. X earned a

VIQ of ___ (_*_%, ___-____), and a PIQ of ___ (_*_%, ____-____). (The * is the
percentile rank for the score.)
The __ point difference between (Mr./Mrs./Ms)'s VIQ and PIQ (is/is not) significant.
(Remember that if it is not statistically significant, it is not likely to be clinically
significant, under most circumstances. That means if the difference is too small to
detect with precise statistics, it is unlikely to be detectable by the naked eye, and
thus have any meaning in describing the persons behavior. Therefore, if there is no
statistical difference, you treat the scores as identical. In addition, there is no such
thing as almost statistically significant. It either is or is not. So, do not interpret
as useful, distinguishing, or relevant a difference that approaches but does not equal
or surpass the cut off for significance!) Next, discuss implications of the difference, if
any exists.
The WAIS-III also yields the following Index Scores and subtest scales scores. Index
scores of 90 to 110 and scaled scores of 8 to 12 are average. (Mr./Mrs./Ms. X) obtained
the following scores.
Score %ile Range
Verbal
___
__ __-__ Perceptual
Comprehension
Organization
Vocabulary
__
Picture Completion
Similarities
__
Block Design
Information
__
Matrix Reasoning
Comprehension
__
Picture Arrangement
Object Assembly
Working
Memory
Arithmetic
Digit Span
Letter-Number
Sequencing

___
__
__
__

__

__

Score %ile Range

___
__
__
__
__
__
__
__

Processing Speed

___

Digit-Symbol/Coding
Symbol Search

__
__

__

__

The FSIQ accurately reflects the persons overall IQ only insofar as it reflects a unified
construct. If VIQ and PIQ are significantly divergent, the meaning of the FSIQ is in
doubt. Similarly, VIQ and PIQ are useful constructs only if their component index scores
are comparable. (In the next iteration of the WAIS, VIQ and PIQ will be eliminated.
VCI and POI are more pure measures of verbal and visual-motor functioning. Compare
these as you would VIQ and PIQ.)
Working down the hierarchy, each index score is meaningful as a construct only if the
subtests that make up that measure hang together statistically. Discuss meaning of X's
scores and their comparisons from the discrepancy analysis page of the WAIS-III record
form using that hierarchy. Discuss both which scores are statistically high, low or
average compared to the general population (nomothetic comparison), and which scores

are strengths or weaknesses when compared to the clients overall functioning

(idiographic comparison). When discussing Working Memory, discuss the meaning of
Digits Forward and Digits Backward, if significant or relevant. Address the assessment
of incidental memory from Digit Symbol - and the recall portion of Bender. Differentiate
poor performance on Coding due to motor vs. incidental memory.
At the bottom of the hierarchy, each subtest accurately assesses performance on its
construct to the extent that intra-subtest scatter is minimal. Discuss any scatter. Look for
patterns in hits and misses. E.g., does the person miss all geography questions on the
Information subtest? All division problems on Arithmetic? Discuss the implications of
any such patterns.
Continue your report by discussing the results of any other achievement or cognitive
testing. There are more useful - and less useful - ways to present achievement test
results. If you are administering these, come talk with me, and Ill help you identify
methods that highlight underlying cognitive processes. Discuss the implications of
such results. Compare with WAIS-III results, and discuss the implications of the
differences. Do not diagnose specific learning disability from ability and achievement
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-achievement discrepancy and deficits in some underlying
cognitive process. Pay attention, therefore, to the underlying processes assessed in all
instruments, as, for example, the index scores on the Wechsler.
Include relevant findings from the MSE, Bender, House-Tree-Person, and Sentence
Completion, TAT, Rorschach, etc. (Neurologically intact or not according to Koppitzs
and/or Lacks criteria, construction complexity on HTP and/or results of DAP scoring of
person drawing; presence of cognitive, motor, or perceptual problems on the Bender,
HTP; number and complexity of responses on the Rorschach; vocabulary usage, fluency
of language, evidence of learning disabilities or higher intelligence in content, grammar,
spelling, punctuation, etc.)
Resolve any discrepancies in the data by identifying the differences or similarities in the
constructs being measured, setting or client characteristics, or task demands. For
example, memory tested using sentence recall, digit recall, kinesthetic recall, and visual
recall may differ, as may free recall versus cued recall. (E.g., do you prefer multiple
choice, or fill-in-the-blank tests?)
Note unusual behavioral responses to test stimuli, or to the testing situation itself,
particularly unusual responses. Alternately, note normal responses when the unusual
would be expected. For example, an allegedly hyperactive child attends, persists,
concentrates, and so forth (might be effect of medication, misdiagnosis, or) Describe
any information gained or performance differences observed from testing the limits (and
describe the method of testing of the limits!).

Try to translate all of this into general terms. What do strengths and weaknesses in the
above areas look like in this persons everyday life? How are they connected to the
presenting problem or other reason for referral?
Sum up this section by discussing the implications of the results. What do they say about
the clients overall cognitive functioning and cognitive style?
Social-Emotional Functioning
Discuss the implications of the person's cognitive strengths, weaknesses, and style for
daily functioning. Address the person's capacity to appreciate reality and control
irrationality, his/her judgment and empathic ability.
Identify the person's primary psychological symptoms, if any. What is the nature of the
person's anxiety? Under what circumstances does the person manifest anxiety? How is
the anxiety manifested? How does the person attempt to cope with anxiety, stress, and
the current situation? How effective are these methods for him/her? Discuss the person's
capacity for appropriate (not too lax, not too harsh) impulse control.
Identify the person's predominant affect and mood. Discuss the persons degree of
responsiveness to affective stimuli, his/her range of affect, and its appropriateness to the
situation.
Identify the cognitive, social-emotional, situational (and biological, if applicable) factors
that underlie the presenting problem, if any, or that relate to the referral question.
Relate the above to the person's lifestyle, presenting problems, and social, academic/
occupational, interpersonal, and family functioning. Identify the person's view of self,
world, others, future. Relate these to the life tasks of work, love, community/friendship
(and self and spirituality). What are the core beliefs that affect the persons functioning,
especially those relevant to the referral question?
Identify the areas in which the person demonstrates psychological strength and positive
qualities. Relate these to the presenting problem and/or referral question.
Summary:
Briefly summarize the report as a whole. Some audiences (judges, busy psychiatrists)
read only the summary, so you must be succinct, clear, and direct. Start with a
generalized mention of intelligence testing results, giving the level of intelligence, and
any noteworthy strengths, weaknesses, or stylistic patterns observed. Then summarize
overall personality assessment results, highlighting the more central and salient aspects of
the persons ality and his/her current functioning.
Clearly and simply relate the results to the referral question, and ANSWER THE
QUESTION in as straightforward and clear a manner as possible. Make sure your

answer is clearly supported by the test data. Give MUCH more weight to the data and to
actuarial interpretation of results than to your clinical impressions. Where 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 PREVIOUSLY
DISCUSSED information and hypotheses. No new information or hypotheses should be
presented here.
Again, CLEARLY ANSWER the referral question.
Diagnosis: Note that for some referral questions, diagnosis is not the issue, and no
diagnosis should be given. For example, pre-employment screening does not require a
diagnosis. For purposes of the assessment sequence and qualifying exams, full, 5-axis
diagnoses must be given.
Axis I: XXX.XX (Write out diagnosis and modifiers for Axes I and II
Axis II: XXX.XX in addition to their codes.)
Axis III: (Medical conditions that impact on the referral question, if any. Note the
source of the information, such as medical file, patient report, or clients
physician, or per DSM-IV criteria. Failure to cite the source can leave you
open to charges of practicing medicine without a license, because you are not
qualified to make medical diagnoses. )
Axis IV: (Psychosocial stressors: list specific stressors, and identify them as mild,
moderate, severe or extreme. Note that the rating is by objective criteria.
Adjusting to a new school is usually a mild stressor, but may become moderate is
preceded by a move at a vulnerable age or by a complication such as coping with
peer reaction to a physical disability, or may be more severe if it comes as a result
of some trauma.)
Axis V: GAF Current:
__
GAF Highest in past year: __
(Note that a persons current level of adaptive functioning cannot exceed his/her
highest level of functioning in the past year, since the day you assessed him/her is
a part of the past year!)
Recommendations: (Use whichever apply of those below, and/or additional or
alternative ones pertinent to the referral question.)
1. Identify whether psychological treatment is warranted. If so, related to what
specific issues? What mode? What kind? What frequency, intensity, setting, and
urgency? To achieve what goals? Of what expected duration?
Example:
Continued inpatient hospitalization is warranted due to Mr. Smiths suicidal ideation
and plan, concurrent severe anxiety and lack of social support.

Individual, outpatient, cognitive-behavioral therapy, once weekly, to address Ms. Jones

adjustment to college and separation anxiety is recommended. Ms. Jones should begin
working with the college counselor this week if possible, as she is considering
terminating her enrollment and returning home.
Ms. Smith should be referred to Kinheart for participation in coming out groups to
help her identify and cope with the issues related to her decision to reveal her sexual
orientation to her family, and to receive support from others after having been outed at
work.
2. Consider medical evaluation? To alleviate what symptoms?
Example:
If Ms. Jones anxiety does not abate within two weeks, the Campus Health Care Center
should schedule Ms. Jones for a medical evaluation to determine whether antianxiety
mediation is needed. Specific attention should be paid to evaluating her sleep pattern at
that time, as she reports sleep deprivation due to excessive worry at night.
3. Further assessment? What kind? By whom (what specialty)? To resolve what
questions?
Example:
Neuropsychological assessment is recommended to assess the extent and nature of
brain damage Mr. Smith has suffered as a result of his substance abuse. Rehabilitation
evaluation is recommended to identify interventions that may help him cope with his
impairments.
4. Non-psychological, non-psychiatric interventions needed? What kind? By whom?
Other agencies need to be involved?
Example:
Given the nature of Mrs. Smiths cultural and religious beliefs, and their impact on her
willingness to seek therapy, consultation with and/or referral to her rabbi is
recommended. This consultation should identify whether the rabbi is capable of helping
Mrs. Smith with her depression, or whether the rabbi can assist her in accepting the
professional help she clearly needs.
5. Environmental interventions needed?
Example:
Johnny needs to be seated at the front of each classroom, so that he is able to see the
board.

This employee should be switched to a position that minimizes interaction with

customers, and provides him with opportunity to socialize with a small cadre of fellow
workers.
6. Issues that might interfere with treatment and how to address them?
Example:
Ms. Jones parents see her as a victim of the universitys impersonal, uncaring
environment. They repeatedly sympathize with and encourage Ms Jones distress.
Unless the parents can be helped to adopt a supportive yet adaptive approach, this
student may fail in her transition to college. It is recommended that the Dean of Students
arrange to meet with the parents and that they be referred to the Parents-in-Transition
outreach program.
Finally, include a formal signature block, which looks like this:
Respectfully submitted,

________________________________
Your name, highest EARNED and RELEVANT degree
Examiner (or Psychology Intern)

________________________
Dr. First Last
Supervisor

Ethical guidelines specify that you should list only your highest degree (or two if
relevant, such as J.D., Psy.D. if you practice mental health law). This means that your
Ph.D. in economics, English, or even education (unless its school psychology) are not to
be listed. Even your M.D. or R.N. are irrelevant, because they did not train you to
perform psychological testing/assessment. For purposes of your education in psychology,
you should list ONLY your M.A. in a related mental health field.
In addition, it is expressly prohibited to list yourself as Psy.D. Candidate.
Professional schools do not recognize or use the term. Traditionally, the term is reserved
for persons who have completed everything for the doctoral degree except for the
dissertation, and whose dissertation proposals have been accepted. Because the path to
the Psy.D. varies from the path to the Ph.D., ISPP does not use or endorse the term. Do
not use it!