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Examinee: Sex: Age: Date of Birth: Place of Birth: Education: Address:
CMB Female 16 August 17, 1996 Makati City 2ND Year High School (not completed) Makati City
The client was referred for testing by an acquaintance. This assessment was conducted to identify possible reasons of her lack of interest and motivation in attending school that made her drop out twice. This is to make recommendations for self-awareness and/or self-improvement.
a. Relevant History b. Clinical Interview c. Battery of Psychological Tests Revised Beta Examination Second Edition (BETA-II) January 01, 2013 Bender Visual Motor Gestalt Test Draw a Person Test Sach Sentence Completion Test` Thematic Apperception Test January 01, 2013 January 01, 2013 January 01, 2013 January 01, 2013 January 01, 2013
Her affect was slightly inappropriate to verbal content. Thought content showed no evidence of delusions. Back then. the client is a 16-year-old female with a recent history of poor school performance and reckless behavior. The client’s attitude was guarded during the interview. The main reason her parents separated was because her father was an alcoholic and oftentimes beat his mother up when they had fights. She also has four older siblings on her father’s side. Eye contact was appropriate. Their mother is not with them at the moment but visits them every weekend. She mentioned beforehand that she was quite nervous of taking the assessment procedures but throughout the examinations. V. paranoia. their quarrels weren’t as worse and got easily resolved. They have recently separated and both now have new partners. There were no signs of hostility and irritability. INTERVIEW AND BEHAVIORAL OBSERVATIONS The client presented for the interview wearing age-appropriate clothing. time and place. Her biological mother was reported to be 39 years of age and is healthy. she was cooperative. RELEVANT HISTORY At the time of the examination. Orientation was intact for person. in fact she was in the honor roll every year. Her biological father is 40 years old.IV. She and her siblings currently live with their father and his girlfriend. She is the eldest of three girls. The client experienced school failures when she started her first . Her parents were not married but lived together for 16 years. She didn’t have any academic problems when she was in elementary. She said that her mother wasn’t understanding and fought back with him which always made his husband snap and hit her. Her speech was clear and unremarkable and frequently joked about being diagnosed of having a mental problem/ illness. and/or suicidal/homicidal thoughts. She was alert and attentive and put forth her best effort in the tasks presented.
VI. She had also thought of running away from home to escape it all. The client demonstrates good reflective thinking but has difficulty showing it to the social world. The request was granted and she continued her studies as a second year high school student.year in high school. smoking cigarettes and drinking liquor. but stopped attending a month and a half later and eventually decided to officially drop out of school. This resulted to her father’s jealousy and suspicion to escalate and from then on. she was gone missing for a night and went home with scratches and had been face-slapped 50 times for initiation and another 50 for punishment because she got scared and decided to quit moments later. Her poor discriminative thinking or judgment to reality situation makes this dilemma possible which might indicate that this prevents her from taking proper action when necessary. The client hesitates in making decisions based on thoughts and responding based on feelings. and activity. her mother got fed up with her father’s attitude which led her to secretly finding herself a new partner. everything fell apart. She is currently not attending school. She consumes 2-3 sticks of cigarettes per day and drinks alcoholic beverages every other day. Whenever she wasn’t at school. recognizing poor behavior. she was with her friends. The client recounted that she had also been bullied by some of her schoolmates. . She even considered joining a sorority group. Her liquor intake goes up to the point of drunkenness and disorientation. attitudes. TEST RESULTS AND INTERPRETATION Results indicated that the client’s overall level of intelligence falls within the Average range as tested by Revised Beta Examination II. The client’s mother talked to the principal to let her enroll for the next school year despite of failed subjects. and setting boundaries for herself against these which result to her behaving in an equally bad way. This was the time when her parents were having serious problems with their relationship.
This can be noticed in her outlook in life. She has plans on striving hard for difficult goals and aspirations and yet always falls short. She recognizes the problem but tends to give everything a much more favorable outcome. The client is reserved and finds it slightly difficult in sustaining meaningful interpersonal relationships for fear of not being able to handle their demands. She compensates for having poor self-concept. She thinks high of them yet sees faults and flaws. She also has contradicting opinions about women. She tends to be superficial and tries not to get emotionally involved with others. This might be the reason why she has peers who she lets influence her to do reckless behaviors because she knows they will not meddle with her personal life. This makes her vulnerable to experiencing impulsivity. . This suggests that she also has suppressed issues with her mother but chooses not to confront it. The client tries to cope with anxiety-provoking situations through optimism. The client has clear gender identity. The client’s father might be a great factor why she feels she needs to protect herself from men. The client also displays the need for family support and attention because of feelings of abandonment and loss. insecurities and continuous failures in life by being ambitious and impulsive. Acting out tendencies is also observed. She copes with the pressure to do what she believes is wrong by giving in to the thoughtless wrongdoing. She still has good concept and opinions on the intimate relationship between a male and a female which implies that she uses these to cover up feelings of sadness.The client manifests anxiety in circumstances involving her family and has poor selfconcept and is insecure. Reservation towards opposite sex is noted.
Family Therapy is recommended. Her reckless behavior might be an unconscious way of calling the attention of her parents. for them to focus on her. She developed poor self-concept and insecurities that root out from her parents’ broken relationship. Through this.VII. She makes up for these feelings by being ambitious. she still behaves in an equally bad manner which she can use as excuses for hiding her issues. But since most of her actions were not approved by them. the client may be equipped with handling current stressors in life and may achieve a better understanding towards them. She fears feelings of being left out and abandoned which are also results of her current family situation. but inclines more on the emotional aspect. to give her just a little amount of their time. The client may also resolve her feelings of insecurities so she will give herself more worth which will promote a much better attitude. RECOMMENDATIONS To resolve conflicts and improve communication within the family members. This will help their family learn new ways of unhealthy patterns of relating to one another. This is obviously not a good idea because she guards herself from being emotionally attached to other people for fear of being overwhelmed by their demands so she ends up hanging around the wrong people. This will improve the client’s troubled relationship with her parents and may help her understand why certain things happen to certain people. CONCLUSIONS/IMPRESSIONS Based on the assessment and evaluation conducted. the client’s IQ level falls within the Average range so this indicates that she does not have any problems in intellectual functioning. this even downgrades her view of herself so in return. The presenting complaint does not come from an issue of not being able to comprehend school discussions. Family Therapy will be a way to slowly build her trust and respect back to her parents because they are a great influence on the . VIII. She does not feel secure inside their home so she resorts to finding comfort in her friends’ company. impulsive and disregarding of possible consequences.
feelings. she will likely be able to handle stressors that will come to her life in the future in a more mature and responsible way. As a result.development of her self-concept. This will alleviate the client’s poor emotional control govern most of what she thinks that often results to impulsivity. If these are resolved. This will sidetrack her in finding comfort and security to behaving inappropriately towards newly introduced options and proper choices. and promote better social behavior. ___________________________ Jamie Ann E. she will likely behave in an age-appropriate way. This will help her be self-aware and increase self-control and suggest fresh possibilities for actions she makes to deal with her problems. Insight Therapy is suggested to help the client discover the reasons and motivations for his behavior. Perdigon Examinee/Psychology Intern . Social skills training is recommended to build coping strategies for dealing with peer pressure and bullying. Cognitive Therapy is advised to exercise better emotional reasoning and view things objectively. and thinking. This will enable her to make good choices in life so as a result she will not yield to any negative influence that other people like her friends introduce to her. improve social skills.
III. Battery of Psychological Tests Revised Beta Examination Second Edition (BETA-II) January 09. 2013 . 2013 January 11. Clinical Interview c. 1975 Quezon City College Graduate Single Psyche Health Home Care II. Relevant History b. GENERAL INFORMATION Name: Sex: Age: Date of Birth: Place of Birth: Educational Attainment: Civil Status: Area of Confinement: Gil Joseph Dela Cruz Male 37 years old November 03. 2013 January 09. REFERRAL REASON The patient is referred for further psychological assessment. ASSESSMENT PROCEDURES a. 2013 Bender Visual Motor Gestalt Test Draw a Person Test Sach Sentence Completion Test Thematic Apperception Test January 09. 2013 January 09.PSYCHOLOGICAL REPORT I. proper treatment and management. 2013 January 09.
He was responsive and open to every question asked and even went to giving each a lengthy explanation. INTERVIEW AND BEHAVIORAL OBSERVATIONS The patient presented for the interview wearing typical casual clothing . When he was in his college years. and a Psychology course which he was not able to finish. Orientation was intact for person. His speech was slightly incomprehensible due to stuttering. He never had any problems with them despite his father being aloof and his younger brother being jealous of his success and achievements. the patient is a 37-year-old male diagnosed of having Schizophrenia Undifferentiated.IV. His biological mother died at the age of 47 due to breast cancer. He has long-healed stitch marks on his left wrist due to attempting suicide. There were no unusual movements besides his occasional mild mouth tremors. He displayed good posture but his movements were a tad slower than the normal. time and place. magical thinking and/or suicidal/homicidal thoughts and there were no observed perceptual disturbances such as visual and auditory hallucinations at the time of the interview although he admitted to having experienced each of these back then. His biological father is reported to be 67 years old and currently resides in the United States.plain blue shirt and shorts. V. RELEVANT HISTORY At the time of the assessment. . he was brought to a home care for rehabilitation for 2 months because his relatives thought he was taking drugs. He had a close relationship with his family. He claims that he knows he has schizophrenia. He is the eldest of three boys. Thought content showed no evidence of delusions. The patient was calm throughout the interview. He occasionally displayed flight of ideas. Eye contact was appropriate although at times he stares a little too long. His mood was euthymic. He also took up Automotive for 2 years. Affect was appropriate to verbal content. There were no signs of hostility and irritability. The patient finished taking up Metallurgical Engineering in University of the Philippines.
Back in rehab. from then on he had been doing it almost 10 times a day. He never had any unusual perceptual disturbances before. There were moving images on the walls of his room. it usually goes up to 210 sticks per day. He was readmitted on the 3rd day of May. He allegedly tried committing suicide four times. 2006 and got discharged in 2010. dried leaves and even his own feces. He also joined a fraternity group. He just talked back. TEST RESULTS AND INTERPRETATION Results indicated that the patient’s overall level of intelligence falls within the Borderline Range. He had been drinking alcoholic beverages almost every day back in college. His guilt feelings had been too much that it once made him try to cut his penis off only his grandfather stopped him from doing it. cockroach. he smashed the glass to create a thunderbolt because he thought he was a god and he had powers. He was a street vagrant for almost a year prior to readmission. 2012. He had tried marijuana. It started after he got circumcised when he was 11 years old. He claims that he heard his brother’s voice and it told him he was proud of him. Though he received proper and complete education. The patient is currently confined in Psyche Health Home Care. it seems that his condition made some deterioration in his intellectual functioning. He was addicted only to cigarette smoking that started since he was 19 years old which his younger brother had introduced to him. His drug intake was only a one-time thing. The patient also had problems with his excessive masturbation. Although his . He even saw his mother in a form a butterfly.He said that he was just depressed because his mother had recently died and he felt hopeless. he couldn’t stop doing it. He got admitted in Psyche Health Home Care on the 6th day of June. Although he felt guilty about this. shabu and cough syrup. it only started on his second time in the home care. He also thought that the world was going to end so he tried eating a worm. VI. his libido was very high.
his decisionmaking skills are still somehow poor because he has problems in discriminative and reflective thinking which help in forming conclusions to situations and making further choices and steps. He also has guilt feelings on being addicted to cigarette smoking. They were all pointed out to someone else tempting him. his colleagues. The patient shows guilt feelings about his excessive masturbation. alcohol and cigarette. although he displays some hesitation in his ability of maintaining it. The patient uses projection as a way of coping with failures. or the hospital attendants. He has fears of castration and has repressed feeling of punishment for having forbidden sexual desires. his brother. He has retained his pride that had come from his past abilities and achievements. This might suggest that he idolizes his father yet has some complaints on him but chooses not to confront him about them since he is his source of motivation and inspiration. . He has good opinions about the intimate relationship between a male and a female since his life-long dream is to have one of his own. The patient has a clear gender identity. He has ambivalent opinions on men. He also has strong fantasies that he uses to channel unacceptable desires into imagination and to ward off self-condemnation. This might suggest that he has slight difficulties interacting with authority figures because he feels that they belittle him in one way or another. He is ambitious and thinks high of himself. He shows feelings of sexual inadequacy which he tries to alleviate by his excessive masturbation.organization of perceived materials appears to be better developed. Evidences of these are his reasons of trying drugs. The patient has no problems with the people around him although he shows some resentment towards those above him. These create some impairment in his judgment to reality situation and abstract reasoning.
He has satisfactory opinions about the relationship of a man and a woman. he is advised to continue his antipsychotic medication to manage psychosis and promote mental wellness. He has guilt feelings towards his excessive masturbation because of castration threats. to learn about himself and to better handle issues of his daily life. He is not experiencing any thought and perceptual disturbances. . He has high opinions about himself which may be the reason why he experienced having grandiose delusions. CONCLUSIONS/IMPRESSIONS The patient’s overall level of intelligence falls within the Borderline range. He uses fantasies to ward himself off from doing these unattainable and forbidden desires. He has a strict superego that morally regulates and controls his needs and impulses. what is not and he can acquire beneficial problem-solving skills. Individual Psychotherapy is advised. This might suggest that he uses these to cover up for his longing of his partner and his dream of having one of his own eventually. VIII. The patient dissents his father for being aloof and a totalitarian but still looks up to him. RECOMMENDATIONS Since the patient is diagnosed with Schizophrenia Undifferentiated. He will be better able to differentiate what is real and. This will be a tool for him to become more able in understanding his condition. He is functioning although some areas show impairment. His moralistic view of the concept of sex contradicts with his impulsive attitude. This might also be the reason why he feels some resentment towards authority figures. by contrast. To further enhance improvement. This may be because his present condition is affecting his intellectual capacity.VII.
Psychology Intern . It will help strengthen his emotional control so it will not be influenced entirely by how he perceives situations given that his decision-making skills are quite poor. __________________________ Jamie Ann E. Perdigon Examiner. This is crucial for both patient and family members. modifying beliefs.If the patient continued his medication and can be deemed as mentally stable and highly functioning. relating to others in different ways and changing behaviors. how to communicate with the patient. and how to be supportive to the patient are all skills that can be taught in family therapy. Family Counseling is for the family’s education about the patient’s condition. Cognitive Therapy is recommended so he can require skills that involve identifying distorted thinking. Learning how to identify changes in the patient.
2013 Bender Visual Motor Gestalt Test Draw a Person Test Sach Sentence Completion Test Thematic Apperception Test January 09. REFERRAL REASON The patient is referred for further psychological assessment and proper treatment and management. 2013 January 09. 1963 Makati City 1st Year College (not completed) Single Psyche Health Home Care II. Clinical Interview 3. 2013 . Battery of Psychological Tests Revised Beta Examination Second Edition (BETA-II) January 09. ASSESSMENT PROCEDURES 1. 2013 January 09. 2013 January 10. GENERAL INFORMATION Examinee: Sex: Age: Date of Birth: Place of Birth: Educational Attainment: Civil Status: Area of Confinement: Narciso P. Joaquin Male 49 years old February 21. Relevant History 2. 2013 January 09. III.PSYCHOLOGICAL REPORT I.
What he uses varies every day.he was wearing a yellow shirt and plaid shorts. He is the second youngest of five siblings. marijuana and cough syrup (Corex D).IV. Sitting posture was slouched and he had a tendency to partially cover his face with his hands. failure to attend school. someone complained against him because he threw a stone at a 14year-old child. He did not have any personal problems. INTERVIEW AND BEHAVIORAL OBSERVATIONS The patient was casually dressed and groomed when he came up for interview . Affect was restricted. the patient is a 49-year-old male with a history of drug addiction and violent behavior. paranoia. There was a time when he entered his neighbor’s house naked and he was under the . He has a broken nose which he got from a fistfight. he only tried it because he saw his other schoolmates doing it. From then on. The patient said that the reason why he was admitted in the home care was because he has psychosis. There were no observed perceptual disturbances. Orientation to time. The patient started taking drugs when he was only 16 years old. His biological parents are both 80 years of age. He consumes half a pack each day.e. V. he had participated in reckless acts (i. Eye contact was appropriate. His school performance in elementary and high school was okay. He was a high school student back then. aggressive behavior. There were no evidences of delusions. RELEVANT HISTORY At the time of the assessment. He was also a cigarette smoker. place and person was intact. His speech was clear but a little soft at times so it was slightly straining to hear what he was saying. He had done shabu. suicidal/homicidal thoughts at the time of the interview. He was admitted in Psyche Health Home Care last July 04. He was calm throughout the interview and answered all questions asked although his attitude seemed to be guarded. failures started in his first year in college. 2011. He got imprisoned three times due to complaints on his behavior. stealing of things). He was drunk and the child got on his nerves.
He attempts to control and address anxiety-provoking situations by being aggressive and assaultive. He denied having experienced any perceptual and thought disturbances such as hallucinations and delusions ever in his whole life. He was first admitted to Plain View Home Care in Caloocan from 2005-2011. Even if he did not take any drug. . He is confined in the said institution up to this day. He has anxiety towards his physical appearance which affects his willingness to build a mutual relationship with anyone around him. he kept bothering a prison guard asking him about his dead friend even though he had only met him. The doctor there told him that he had psychosis. his behavior was still the same. He is sensitive to criticisms so he creates a barrier between himself and the people around him. He was admitted in Psyche Health Home Care shortly after he escaped in the former institution. while he was in jail. This might be the reason why his attitude is always guarded. He has a poor self-concept. TEST RESULTS AND INTERPRETATION Results indicated that the patient’s overall intelligence level falls within the Dull Normal range. His poor recognition of destructive behavior makes it difficult for him to set boundaries for himself against participating in it. He had smashed a car’s windshield for no reason. In another instance. VI. he always acts out on his impulse. He has good reflective thinking but his discriminative thinking skills are poorly developed which hinders his ability to make proper judgments and avoid jumping into conclusions without considering all the facts. The patient has feeling of lack of autonomy or self-government and he has a strong need to control threatening impulses but since his poor judgment hinders his decisionmaking. he allows only a few people in his life for fear that others might not really accept him for who he is.influence of shabu.
Although he wants one of his own. he does not welcome the idea of considering having a partner for fear of being overwhelmed by the demands. He tends to develop acting out tendencies to avoid of being conscious of the emotions that accompany them which often results to bad behavior. the stress of caring for somebody can place a strain on any family. After experiencing an episode of psychosis. His low selfesteem leads to self-criticism and self-doubt. He is not comfortable with the idea of being with someone intimately because of anxiety and guilt he feels towards himself. RECOMMENDATIONS Family Therapy is recommended for helping both the patient and his family to cope better with his condition. He has a poor self-concept which roots out from his guilt feelings on previous wrongdoings and anxiety towards physical appearance. he may rely on his family members for care and support. He acts out impulses and desires in spite of his conscience and he does them with relatively little thought instead of reflections and feelings. he does not really consider having an intimate partner for fear of not being able to maintain it. anxiety and even shame. CONCLUSIONS/IMPRESSIONS Patient’s overall level of intelligence falls within the Dull Normal range. He has a clear gender identity and although he wants one of his own. This hinders his willingness to even start out a meaningful relationship. he tends to develop acting out tendencies. To cope with anxiety. This behavior roots out from internal emotional conflicts. He has a poor judgment to reality situation and tends to alleviate feelings of anxiety caused by certain situations by being aggressive and assaultive.The patient has a clear gender identity. This will . While most family members are happy to help. He always acts out impulse and gives everything little thought. VII. VIII.
Stress worsens the patient’s ability to think rationally. he can prepare for it and work out how to control it when it happens.help them decide how to solve practical problems caused by psychosis – for example. Psychology Intern . When he improves his social skills or change selected behaviors. His irritability and use of alcohol and drugs back then may be a sign of poor coping. Perdigon Examiner. Social Skills Training is recommended to help the patient with his difficulties in relating to other people. planning how to manage a future psychotic episode. By anticipating stress. Stress Management is advised since the patient has a poor way of coping with it. ___________________________ Jamie Ann E. he will raise his self-esteem and increase the likelihood that others will respond to him favorably.
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