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PSYCHOLOGICAL EVALUATION (Confidential Information) Name: Date of Birth: Gender: Norshan V.

Liwag October 3, 1992 Female Referral: Academic purposes

Reason for Referral: Norshan is a 20 year-old, right handed, single and currently a 4th year student taking up a bachelor’s degree in Clinical Psychology. The patient was referred to undergo psychological testing in partial fulfillment in the subject requirement Personality Assessment and Evaluation. Procedures: List any procedures completed, in order of administration. In the standard approach to assessment, procedures are administered in a “peel the onion” order. For assessment courses in graduate school, include “Clinical Interview” in your list, even though you may not conduct a formal interview, to reflect your collection of any background information. There is not really a “standard battery” for assessing children. An assessment for learning disabilities purposes should include intelligence, achievement, and emotional components, tailored to assess the components of the possible problem – and to rule out competing hypotheses. That is, it might be a reading disability – or it might be depression, anxiety, OCD, and so on… so be sure to adequately gather information for and against alternative hypotheses. The traditional “standard battery” consists of those tests marked with a *. Delete the * in the list below. Answering the referral question will usually require that the list be altered to include more, fewer, or different assessment methods. Clinical Interview (specify interview of parents, child)* Wechsler Intelligence Scale for Children - IV (WISC-IV)* Woodcock Johnson Test of Achievement – III Bender-Gestalt Test* House-Tree-Child* Incomplete Sentences Blank* Minnesota Multiphasic Personality Inventory – Adolescent Version (MMPI-A)* Thematic Apperception Test (TAT)*

Child Name Rorschach Inkblot Method* Others as needed to answer the referral question, such as review of educational records, review of prior testing, the Gray Oral Reading Test, Conners’ ADHD scales, Achenbach Child Behavior Checklist, and so forth. List contacts with teachers, social workers, pediatricians, etc. Background Information: Throughout this template, I am referring to both children and adolescents when I say “child”.

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Include here information regarding the following topics, as relevant to the purposes of the assessment. This list is given to provoke your thinking and to encourage you to be thorough, wherever such thoroughness is warranted: • Identifying information including age, gender, ethno-cultural identity, year in school. • Describe the family context. Be careful about reporting that the child is adopted, or that one parent or another is a stepparent, or that “Mom and Dad” are actually “Grandma and Grandpa”. If the child has not been told, you might not want to put it in writing. What is the child’s birth order? Do not name relatives other than parents. Instead, refer to them by relationship; e.g. “older brother”. • Presenting complaint and symptoms; o History of the presenting complaint including onset, duration, course (times when it’s better or worse); o Whether the problem seems to be improving or worsening as the child gets older; o Prior treatment efforts and success of these; o The parents’ and child’s (teacher’s, pediatrician’s?) conceptualization of the problem; • Relevant personal history o Critical events in development and timeliness of meeting developmental milestones o Life stressors in the time period preceding the presenting problem and preceding the referral for evaluation o Changes in the family situation prior to the onset of the symptoms (birth of a sibling, older sibling left for college or marriage, family moved, best friend moved away, finances changed, parent got ill, etc.) • Academic history o Grade in school o School performance a/e/b report cards, teacher’s written comments over time, GPA, recent work handed in and graded, and similar hard data o How the child performs in reading and math (basic skills) as well as other subjects – parent, teacher and child perspectives.

teacher characteristics. breadth of the group. and attitudes are required for success and happiness on the job? Make sure you actually understand what the adolescent is supposed to do when he or she is at work. weekly basis.  What jobs they have previously had  Level of accomplishment a/e/b promotions. whether friends are considered positive influences by parents and teachers. • Occupational history for adolescents where applicable o What jobs the adolescent has had  Functional job analysis – what do they actually DO on a daily. consider the good of the child and need to know before you put something in writing or share it verbally. teacher and parent perspective. Some of this is none of a school’s business. added responsibilities. Look at this chronologically for clues as to the evolution of the presenting problem or question. Are those constant? Time of day those classes are scheduled. o What the child recalls about learning to read and do math. and 2) appropriate to share with a general audience. o Whether any special assistance or accommodation has been needed or granted before this assessment. Bear in mind that adolescents between 12 and 18 may be able to suppress some information they share with you – even from their parents. Terra Nova tests) and any previous individual ability or achievement testing. including results of both standardized group achievement tests (E. Know the law.Child Name 3 o Best/worst classes. awards. follow it.. whether the older child/adolescent has changed friends lately or at the onset of the . environmental disruptions. What knowledge. other factors affecting performance in those classes (ask the child!). o Parental expectations and standards o Setting effects: study area at home. Ask. skills. if relevant and necessary to the evaluation o Review of previous psycho-educational assessments. etc. and supervisees o Parental expectations and standards o Whether any special assistance or accommodation has been needed or granted before this time o Permission to speak with employer if relevant and necessary to the evaluation • Social history o Report in writing only what is 1) relevant to the referral question. supervisors. evidence in submitted work. Don’t assume. o Number and length of friendships.  The child’s report of how easy or difficult it was to learn the job  What they feel they do well and not so well  What they like and dislike about the job o Quality of interactions with peers. what is hard/easy for them from their perspective.g. o Permission to contact school. and effect of that intervention. etc.

level of commitment. pregnancies/abortions. hospitalizations. particularly ear infections. whether to this child or others. variety.) o Physical skills: walking. and personality?) o Satisfaction/dissatisfaction with friendships. chronic illnesses.Child Name 4 problems. task and time demands of the activity. athletic or musical skills. o Success of social activities a/e/b length and persistence of relationships. any traumas within the friendship group. “tics” or other neuromuscular disorder o Any hospitalizations  What for and when  Length of hospitalizations . coloring and writing. and the like o Childhood illnesses. community. why. practices the instrument. asthma. sentences. whether the child is popular.. dystonia. coping method. congenital or inherited neuro-muscular problems such as cerebral palsy. dating o Quality and appropriateness of interaction with members of peer group. especially…  Chronic illnesses  Diabetes  Thyroid problems  Metabolic problems  Fibromyalgia. walking. etc. course. Ask a dating adolescent if he/she is sexually active. legal. STD protection. juvenile or osteoarthritis. demonstration of appropriate judgment and impulse control in history • Medical and developmental history o Age at which major developmental milestones were attained (crawling. too lax. duration. or other pain or functional disorder/disease  MS or other degenerative disease/disorder  Cerebral palsy. bullied. accepted.g. and community o Any difficulties – onset. too many. ostracized. parental expectations o Congenital or neonatal history. family. situational analysis o Capacity to tolerate being alone. either episodically or cumulatively o Later illnesses. high standards. etc. carpal tunnel. standards adjusted for child’s ability. anything that could interfere with school attendance. history of break-ups (who. ethical rationale for doing so. comparison with peers. and so forth. etc. first word.) o Parental expectations and standards (too loose.) o Whether the older child or adolescent is “dating” (check idiosyncratic meaning). bike riding. ask about birth control. injuries. cooperation and reliability in group activities (e. impact?). temperament. gets to practice on time. o Typical social activities and type and level of involvement in extracurricular activities (too few. and if so. patterns. Consider such information in your assessment. dystonia. etc. who they date. but do not put it in a written report without a clear.

 Impact on presenting problem  Corrective measures or treatment  Efficacy of corrective measures  Whether the child is using those corrective measures at the time of testing o Medications taken previously or currently. vision. “Is it working? How long does it take to “kick in”? o Substance use:  Alcohol and street drugs the child “has tried”  When started. what for. orthotic. what didn’t  What the child and parents liked/disliked  Long-term outcome  Relationship with treating clinicians o Prior psychological or psycho-educational assessment or testing .)  Prior efforts to quit  Social system’s reactions to use o Last physical checkup  Results  Whether parents have discussed the presenting problem with the pediatrician  Parents’ and child’s relationship with medical professionals o Permission to contact physician if relevant and necessary to the evaluation • Psychiatric/Psychological history o Previous psychiatric or psychological treatment  With whom. complications. current types and levels of use in dosage and exact frequency  Last use  Effects and impact  Side effects  Legal issues (Consider a formal substance abuse history where indicated. or sequelae?  Success of treatment o Hearing.Child Name 5  Any problems. or vestibular problems.  Type and dosage  What for  Efficacy  Side effects the child experiences  How long they’ve been taking it  Whether they take it regularly as prescribed  Last time they took it (date and time)  If today. largest amount consumed and when. when and for how long  Efficacy  What worked.

grandparents. To clarify. indeed. That belongs under "results". X’s older brother”. “John Smith. they are a form of objective data. “John appeared to be using a kinesthetic approach to Matrix Reasoning. etc. X’s uncle”. It reports your general observations of the child.). Ps. grandparents. Gs.g. Ps.g. saying it reminded her of her mother” does not belong here (if. Sibs. Keep this section descriptive. This section also does not include the child's response to specific test stimuli. Observations are what a video recorder would pick up. after test results (the data that informs the conclusion) have been presented.” is a diagnostic conclusion. or that might have affected the validity of testing. As & Us  Level of acculturation of family • Length of time in US. social modeling)  Occupational functioning in parents. Mr. Thus. interruptions in the testing. Mr. siblings (predicts target functioning level or self/other expectancies)  Relevant medical history. familial demands. X’s uncle” versus. not evaluative or conclusive. . two or more sessions. This not the place for diagnostic statements. parents. E. as it describes the child’s ongoing anxious state. Sibs  Psychiatric history. “Mary appeared to be suffering from a generalized anxiety. “older brother” versus “Tom Smith”.” belongs under test results because it indicates not a state. and belongs at the end of the report. background noise. Behavioral Observations: This section should describe what the child brings to the testing. Gs.  Permission to speak with family members if relevant and necessary for the assessment • Note: Do not name family members. “Mary laughed upon being presented with set 4 of the Picture Arrangement subtest.. Refer to them by relationship only. Finally. but an approach to the particular task.Child Name    • Family history   When? Why? Results – get copies if at all possible Interventions and efficacy 6 Adopted or related by blood (careful!)? Academic accomplishments and problems in siblings.. it is useful at all!) because it is a response to a specific test item. aunts & uncles (think genetics. “John became increasingly anxious as testing progressed and refused to complete the some tasks” does belong here. DO include here the following: Setting constraints on testing (e. Generally. child and parent “generation” in US • English-language fluency • Conflict or acceptance of US cultural norms relevant to the referral question or diagnoses under consideration. interference. “Mr. you want to relate any environmental conditions that might have made it difficult for the child to put forth his/her best effort. In addition.

such as on the job. List any reported or observed handicaps to sensory-motor functioning: glasses or contacts (to correct what?). and appropriateness to content during the interview and formal testing. but the results may not indicate prior functioning or predict future functioning. For example.g. Note especially the last set in the above paragraph. and that the test results are not unduly influenced by situational factors. pressure.Child Name 7 The parts of the Mental Status Exam that are readily observable belong here.” “Based on the clear and persistent discrepancy between John’s test responses and his behavior during breaks from the testing. “Typical functioning” means you think this is the way the child functions generally.” (Such as happened in one personal injury assessment I observed. such as psychiatric. and effort. provided you were able to motivate him/her to perform well.) . or who is severely depressed. Report on the child’s ability to separate from parents. such as overtly anxious statements. labile. you are testing a child who is recovering from brain injury. fluidity. underestimate) assessment of his (typical functioning. Report on the child’s ideation evident in behavior. Note the parentheses. you might be evaluating a child for accommodation on the job. test results are likely to be an (accurate.. functioning at this time. discuss the child’s appearance if it is noteworthy or related to referral question. or potential)". and there were no situational or other constraints. place and time. hand tremors. for example. hearing aid. range of expressiveness (flat. Note his or her orientation to person. This is appropriate when. persistence. these tests results are likely to accurately reflect his true potential. Observe speech quality. etc. or rehabilitation/neurological settings. the test scores are likely to reflect his attempt to manipulate the outcome of the assessment rather than the “truth” about his capabilities. "Based on John’s behavior. persistence. cooperation. you could say. and his/her apparent attention and concentration. parentheses suggest alternatives. intonation. suicidal/ homicidal comments. Some examples: “Based upon John’s obvious cooperation. Throughout this teaching template. Describe the child’s affect (visible display of emotion) in regard to feelings displayed. animated/normal). e. as well as reticence or garrulousness. “Current functioning” means this is the way the child is functioning NOW. especially in settings where that might be in question. and effort – the conative factors involved in performance. evidence of delusional or hallucinatory thinking evident in behavior (as opposed to evident in test results). “Potential” indicates you are trying to predict how the child will function in the future. Then make a statement about your sense of the validity of results. based on the full collection of behavioral observations and the child’s history. speech problems. For example. forensic. For example. and the test results may reflect about how well the child can be expected to perform at his/her best. or in school. gait or motor problems. modulation. and his apparent effort and cooperation.

This last statistic is called a percentile rank.” An IQ of 90 to 109 is average. as appropriate to the referral question. due to her familiarity with the test materials. effort. If you TAB over to each cell. Academic Skills and Achievement.Child Name 8 “Based upon John’s lack of cooperation and his difficulty with concentration and persistence. Do not use underlining in the report itself. these results likely accurately reflect her functioning under the influence of her depression. (His/Her) general intelligence of ___ is higher than that of ____% of (children/adolescents) (his/her) age. (Child’s name)'s performance on the WISC-IV places (him/her) within the (average/ above average/ superior/ borderline/ extremely low) range of intellectual functioning.” You are 95% confident that the child’s “true score” falls within the given interval of scores. and obvious desire to succeed. (Child) obtained the following scores.” “John’s history and his cooperation with the testing procedure suggest that the results reflect his typical functioning. they may accurately reflect his functioning under the current stress of family disruption. Note: here and throughout. Reading Problems. The WISC-IV also yields the following Index Scores and subtest scales scores. Discuss the implications of the child’s general ability for the referral question.” Cognitive Functioning: Select appropriate phrases. Consider using subheadings: General Ability. there is a 95% chance that (his/her) score would fall between ___ and ___. and so forth. concentration. rather than the general heading above. despite her cooperation. The last phrase is the “confidence interval.” “Based upon the number of interruptions and the less than optimal testing conditions. Don’t confuse it with being “95% sure of your results. However. Contextualize the child’s general ability by referring to those things in the child’s life that fit with their overall ability. include a page break before the table. The following table should appear on one page in your final report. If necessary. Index Score %-ile Index Score %-ile . In your report. Index scores of 90 to 109 and scaled scores of 8 to 12 are average.” “These test results may slightly overestimate Mary’s true abilities. underlines are space holders. More data might appear in your table if you are using the WISC-IV Integrated. these results likely underestimate his true potential. and cooperation. with no break. Were (s/he) tested again under similar circumstances. cell boundaries of the table will not print. you will be able to replace the data below with your child’s data. particularly on Performance tasks.” “Based upon Mary’s effort. these results likely underestimate Mary’s true ability.

Let me make this clear: if there is no statistical difference. under most circumstances. For example. and . Be careful here. but also attend to the component scores that contribute to that aggregate in interpreting it. regardless of how they compare to the child’s overall ability. If the difference is too small to reach statistical significance. A score that is significantly different from average (<90 or >109 for IQ and index scores) are strengths or weaknesses relative to the general population. It either is or is not. When discussing significant discrepancies between index scores. if the child’s FSIQ is 140. So… the FSIQ is the best predictor of a child’s general ability.Child Name Verbal Comprehension Similarities Vocabulary Comprehension Information Word Reasoning Working Memory Digit Span Letter-Number Sequencing Arithmetic 108 (101-114) 9 70 75 84 50 63 91 68 75 63 84 Perceptual Reasoning Block Design Picture Concepts Matrix Reasoning Picture Completion Block Design w/o time bonus Processing Speed Symbol Search Cancellation Coding CA Random/Structured Cued/Free Recall 127 (117132) 14 12 17 10 15 97 (88-106) 11 11 8 10/11 96 91 75 99 50 95 42 63 63 25 50/63 >25% 12 13 10 11 14 107 (99-114) 12 11 13 In interpreting results of intelligence tests – or any other test that has subscores – you can take a top-down or bottom-up approach to interpretation. or relative weaknesses if lower. or relevant a difference that approaches but does not equal or surpass the cut off for significance! These cautions are necessary both because our tests are not perfectly precise tools. Think about the aggregate scores as most reliable. When discussing each “index area”. first identify where the child’s ability is relative to the general population (normative range). but the score accurately reflects his or her overall ability only insofar as it reflects a unified construct. The best approach is to do both simultaneously. distinguishing. or to make a difference in the child’s functioning. you treat the scores as identical. and because people are not perfectly consistent over time. Do not interpret as useful. it is unlikely to be detectable to the observer or to the child themselves. and thus will not have any meaning in describing the child’s behavior. consider the child’s overall ability the “baseline”. there is no such thing as “almost” statistically significant. Any difference between index scores or subtests that is not statistically significant is not clinically significant. Index scores significantly different from that baseline represent relative strengths if higher. “Relative” means relative to the child’s own average – the “local norm”. and do not discuss the (illusory) difference in the report. Also.

what accounts for that? Consider the sensory-motor stimulus-response demands of the task. according to the CHC theory of intelligence. and so on. Compare VCI and PRI as you would VIQ and PIQ. In some ways. At the bottom of the hierarchy. when describing differences from the child’s overall ability. Look for patterns in “hits and misses. You must include the term “relative. and do not assume. the reader assumes the child can’t do things as well as the average child his/her age. and so on.” E. “drill down” from larger pools of data – index scores . rather than differences from the normal population (between-persons comparison). Discuss both which scores are statistically high. In the next sections. Working down the hierarchy. or are they discrepant? If discrepant. each subtest accurately assesses performance on its construct to the extent that intra-subtest scatter is minimal. identifying .” or some other verbal indication that this is a within-child comparison. in looking to understand differences in the child’s performance on different subtests within the same index. each index score meaningfully assesses a unified construct or aspect of intellectual functioning only if the subtests that make up that measure “hang together” statistically. If you only say it is a weakness.. and which scores are strengths or weaknesses when compared to the child’s overall functioning (ipsitive comparison).g.Child Name 10 Processing Speed is 120. Discuss whether the constructs assessed by each index area operate as unified wholes. For example. you might consider whether the child’s scores vary according to Bannatyne’s factors.to individual data points (individual items) to reveal patterns in the child’s performance. do the subtests that make up the index area co-vary. the WISC-IV is a very different animal from the WISC-III. whether scores rose or fell depending on whether there were time limits. compared to the VIQ and PIQ found in the WAIS and previous editions of the WISC. low or average compared to the general population (nomothetic comparison). and their comparisons from the discrepancy analysis page of the WISC-IV record form using that hierarchy. Verbal tasks on the WISC-IV are of two types: those measuring verbal comprehension and those measuring working memory. Discuss the meaning of the child's index scores individually. answering questions requiring common sense or common knowledge. but be careful. PSI may be a relative weakness compared to the child’s other scores. Verbal Comprehension tasks include defining words. how the cognitive demands of stronger and weaker tests varied. whether scores fell as time went on (a fatigue effect). That is. does the child miss all geography questions on the Information subtest? All division problems on Arithmetic? Discuss the implications of any such patterns. and that much of the research on the WISC-III and its predecessors applies to the WISC-IV. whether the child displayed different levels of anxiety. but it is still significantly stronger than the score for the average individual the child’s age. It is likely that most of the research on VIQ-PIQ differences applies fairly well to VCI-PRI differences. Discuss any scatter. Address any other important patterns or discrepancies. VCI and PRI are relatively “pure” measures of verbal and non-verbal reasoning. according to whether the task requires more simultaneous or more sequential processing.

or other relevant patterns. especially if persistent. Verbal comprehension is strongly related to overall ability and academic performance. if different from what was displayed on other tasks. as described in the section above. for example. Both immediate auditory recall of meaningless information (Digit Span and Letter-Number Sequencing) and recall and processing of meaningful information (Arithmetic) are assessed in this area. 11 In the paragraph on Verbal Comprehension. . Add observations as appropriate. not the test. keeping track of what he/she reads sufficient for comprehension. if significant or relevant. selectively attend to some information while ignoring other information. Talk about the child. as assessed by VCI alone. (higher/lower) than NN% of children (his/her) age. and perform mental tasks using a step-bystep logical approach. remembering complex or multi-step instructions. Emotional response. such as using math knowledge to solve longer problems. Discuss any significant differences between subtests. and theoretical constructs being measured. Contextualize and individualize this description. the child’s history. Address the assessment of incidental memory from Digit Symbol . taking organized notes during a lecture. and using verbal clues to “construct” a concept. Discuss how the abilities assessed by VCI and WMI affect each other. in light of the referral question. Spartan or verbose responses. Child (here include some examples of working memory as it might show up in the child’s life. Note. Point out any discrepancies between specific abilities the subtests identify and what the differences imply. by analyzing how the tasks in subtests with higher and lower scores differ in terms of needed skills.) Discuss the implications of the score given the referral question. On these tasks. Working memory is engaged when. stimulus and response modalities. in light of stimulus factors (auditory) and response factors (verbal). and so on. or whether language processing affected the Arithmetic subtest.Child Name similarities between two concepts or words. the context to which you are predicting. Discuss the implications of any significant difference or lack thereof. whether retrieval difficulties or problems with incidental learning appeared to impact Information. How do these relative strengths and weaknesses function in the child’s life? How do they relate to the referral question? Discuss any noteworthy response patterns or behaviors the child demonstrated when presented with these tasks. word-finding difficulties. need for repetition or encouragement could all be discussed. Idiosyncratic responses to items or idiosyncratic problem solving methods that may be relevant to diagnosis or referral question should be addressed.and later relate this to the recall portion of Bender. (higher/lower) than about NN% of children (his/her) age. (Child) scored in the (name the range using Wechsler’s terminology) range. performing mental math. Use examples that fit the child’s context. Speech patterns. The subtests that make up the construct Working Memory measure the ability to hold information active in mind while solving a problem with it. function in his/her life. response latencies. discuss how the child’s abilities or difficulties. concentration. for example. and so forth could be discussed here. Child’s Working Memory score is (name the range). Identify any relevant commonalities in the child’s approach to these tasks. adding long rows of numbers. Compare and contrast the child’s abilities as assessed by VCI and WMI areas. Discuss the meaning of a difference between Digits Forward and Digits Backward. and so forth.

Child’s intelligence test results indicate that (he/she) thinks at a (name the range) level. did the child lose points on Block Design due to slow speed? Were his/her responses to verbal subtests delayed? Compare and contrast the child’s abilities as reflected in PRI and PSI. higher than NN% of (children/adolescents his/her) age. Briefly reiterate areas of absolute and relative strength and weakness. Continue discussing as above. If additional or other academic tests were administered. if you administered it. The first of these. required Child to construct visual models using a visual guide. incidental learning problems. and discuss the implications of the differences. read maps. Perceptual Reasoning. follow demonstrations in science. Differentiate poor performance on Coding due to motor vs. Child’s ability in this area is (name the range). set up math problems in columns. and you may need to alter the table.Child Name 12 Non-verbal problem solving tasks on the WISC-IV are of two types. as well as any other incidental learning issues. read social cues. and the speed with which (he/she) makes decisions. Discuss the meaning of any difference between Cancellation Structured and Random. For example. make sense of geometry. I’ve provided one way to set up Woodcock Johnson test results at the end of this report. and any critical patterns and observations. and relate this to the “recall” portion of the Bender. understand graphs. (higher/lower) than NN% of children (his/her) age. Learning disability assessment is shifting . some of the general indices will not be computed. using all – or nearly all -subtests available for each. Processing Speed tasks assessed the speed with which (Child) learns material presented visually. Overall. the GORT. discrimination between similar letters. Continue your report by discussing the results of any other achievement or cognitive testing. Discuss the implications of such results. and identify important missing visual details. That is. Discuss the implications of the child’s perceptual reasoning for academic functioning – given this specific child. Comment on any problems with retrieval speed or response latencies observed on subtests other than those directly assessing processing speed. compare and contrast the child’s verbal and non-verbal reasoning abilities next. report results and what they mean about the child’s abilities here. If you administer only the basic subtests. perform hands-on problem solving. compare and contrast their abilities as reflected in PRI and VCI. which is where I include them. such as Key Math. not the scores. ability to track across and down a page when reading. it might affect the child’s handwriting. the WRAT-III. Compare with WISC-IV results. solve abstract visual problems. For example. given visual information. What are the implications? Talk about the child and their relative abilities. (his/her) visual alertness. (Child)’s abilities in this area were (name the range). Continue discussing as above. Since POI and VCI are the most “pure” measures of reasoning. I’ve given set-ups for both cognitive and achievement results. copy from the board. and so on. understand complex ideas presented visually. or find his/her way around the school. subtracting out WMI and PSI.

what seems to be the problem? How does that explain actual academic performance in the classroom? Include relevant findings from the MSE. Bender. What do they say about the child’s overall cognitive functioning and cognitive style? Social-Emotional Functioning Consider a different heading than the above. For an anxious child. Pay attention. evidence of learning disabilities or higher intelligence in content. familiar/contextual vs. did it?). and language skills evident in TAT.) Resolve any discrepancies in the data by identifying the differences or similarities in the constructs being measured. For example. as. and so forth (might be effect of medication. therefore. HTP. What are the implications of these differences for the child’s ability to perform as expected in his/her context? Note the child’s behavioral responses to test stimuli. or task demands. Is the child performing as would be expected from his/her intelligence test results? If not. it might say. to the underlying processes assessed in all instruments. numbers. note normal responses when the unusual would be expected. motor. punctuation. fluency of language. memory tested using sentences. or spatial location. “John’s Ability to Cope with Anxiety” . words. persists. construction complexity on HTP and/or results of DAP scoring of person drawing. vocabulary usage. Alternately. or…) An adolescent claims not to be able to do a task on the test. What do strengths and weaknesses in the above areas look like in this child’s everyday life and the contexts in which he or she lives? How are they connected to the presenting problem or other reason for referral? Sum up this section by discussing the implications of the results. number and intactness of responses on the Rorschach. etc. particularly unusual responses. visual vs. nonsense/out-of-context stimuli.Child Name 13 from solely an ability-achievement discrepancy to include an assessment of strengths and weaknesses in cognitive processes thought to underlie learning. yet performs a similar task during breaks without difficulty. presence of cognitive. grammar. complexity. Translate all of this into terms relevant to the child’s life. or perceptual problems on the Bender. “Behavior” or “Behavioral Problems and Strengths”. or to the testing situation itself. on Sentence Completion. the index scores on the Wechsler. and so forth. auditory stimuli. it might say. and free versus cued recall may differ. House-Tree-Person. (Koppitz’s and/or Lacks’ criteria. concentrates. misdiagnosis. coherence. Describe any information gained or performance differences observed from “testing the limits” (and describe the method of testing of the limits – which did not violate test security. and Sentence Completion. For example. For example. Rorschach. orderliness. setting or child characteristics. TAT. for example. in reporting results for a child with ADHD. mixed stimuli. an allegedly hyperactive child attends. spelling.

carefully consider the reciprocal influence of child/adolescent and environment in describing the child/adolescent. emotion. to delay action. this year’s teacher. or whatever. and style (as reported in the prior section) for daily functioning. Address his/her ability to appreciate reality and control irrationality. under what circumstances does the child manifest anxiety? How is the anxiety manifested? How does the child attempt to cope with anxiety. his/her judgment and empathic ability. What is the nature of the child's anxiety? I. and young adult as in development. “incongruence”. if any. rather than set in stone. children do not select their environments. and likely areas of difficulty in solving social-emotional problems based simply on cognitive strengths and weaknesses. maintain. In addition. Personality is in the process of being created. and so forth) than for adults. it’s especially important when describing children. to cope with frustration? Again. or keeping the child stuck in development? Identify the child's predominant affect and mood. his/her range of affect. Start by discussing the implications of the child's cognitive strengths. or emanate from this core? What environmental factors might be contributing to. Identify the child's primary psychological symptoms. or behavior. the unique combination of personalities in the child’s peer group. and its appropriateness to the situation. neighborhood. If you could identify a basic direction of movement (a developing personality style. adolescents. stress. not hard-set. modifying. and the current situation? How effective are these methods for . it is critical to take a developmental perspective. contribute to. While this is important for all clients.. weaknesses. what would it be? If this is the core of the child. but my core approach is CBT. contextualize this in terms of social learning theory and other environmental factors. Alter all of the below to fit your theoretical orientation. Describe the child. But talk about the child. While staying true to the data that emerged from the assessment. not their “mirroring transference”. how do the rest of the characteristics or symptoms relate to. and is more plastic in young adulthood than in older years. or the core of his or her problem. and young adults. global level of education in the neighborhood. or maintaining the problem cognition. the school as a whole.e. Talk about the social and self-skills they have or have not developed YET. adolescent. Address the child's capacity for self-control. SES. if you will) or diagnostic characteristic. in children. on the whole. about how far they have come and where they are going next. and it is therefore much more critical to consider social environment effects on their performance and behavior (family. What is his/her capacity to delay gratification. Discuss the child’s degree of responsiveness to affective stimuli. In describing children through college aged individuals. his/her ability to initiate and maintain friendships. Describe the child so that their grandmother and best friend would recognize them from your description.Child Name 14 Caveat: I conceptualize clients from a multi-theoretical perspective. “oral fixation”.

social-emotional. future – and describing these as in the process of development.” as research says the former is likely to be more accurate. rather than fixed. say so. Make sure your answer is clearly supported by the test data. academic/occupational. not too harsh) impulse control. Relate these to the life tasks of work. For example. others. diagnosis is not the issue. and social. No new information or hypotheses should be presented here. community/friendship. Give MUCH more weight to the data and to actuarial interpretation of results than to your “clinical judgments. Then summarize overall social/emotional assessment results. Identify the child's emerging view of self. Relate the above to the child's presenting problems. especially those relevant to the referral question? Identify the areas in which the child demonstrates psychological strength and positive qualities. Where there is conflict between clinical impression and data. Some audiences (judges. if applicable) factors that underlie the presenting problem. self and spirituality. How does the child use these strengths in his/her life? How do they mitigate the presenting problem or add to an understanding of the referral question? How might the child’s strengths be used in therapy or in the situation to which you are “predicting” to improve the child’s functioning? How will those strengths continue to affect the child’s development. or that relate to the referral question. and any noteworthy strengths. peer-group. and no diagnosis should be given. pre-employment screening does not require a . world. situational (and biological. Summary: Briefly summarize the report as a whole. and ANSWER THE QUESTION/S in as straightforward and clear a manner as possible. describe your conclusions and rationale for them. clear. weaknesses. if any. busy psychiatrists) read only the summary. Clearly and simply relate the results to the referral question. Diagnosis: Note that for some referral questions. highlighting the more central and salient aspects of the child’s developing self.Child Name 15 him/her? Discuss the child's capacity for appropriate (not too lax. NOTE: Information and hypotheses listed in the summary should reflect PREVIOUSLY DISCUSSED information and hypotheses. and direct. and family functioning. What are the emerging core beliefs that are affecting the child’s functioning. so you must be succinct. and his/her current functioning. love. What was the referral question? What is the child’s general level of intelligence. Check to make sure you have CLEARLY ANSWERED the referral question. and help the reader know how to handle the discrepancies. Identify the cognitive. identify which is which. or stylistic patterns observed.

Place major recommendations first. Note that the rating is by objective criteria. if something needs to be done emergently. for easy digestion and referral.) Axis V: GAF Current: __ GAF Highest in past year: __ (Note that a child’s current level of adaptive functioning cannot exceed his/her highest level of functioning in the past year. patient report. Consider interventions that need to be done at school. or “per DSM-IV criteria”. that a therapist should help with.XX (Write out diagnosis and modifiers for Axes I and II Axis II: XXX. when needed. If there is no diagnosis on either of these axes. should be anything urgent or emergent: the need to hospitalize. 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. severe or extreme. don’t wait for the report to be written to get in touch with the child. since the day you assessed him/her is a part of the past year!) Recommendations: Use whichever apply of those below. and identify them as mild. Present recommendations in numbered outline format. ..g. For doctoral students in assessment courses and preparing competency examinations. to urgently have the child assessed for medical or neurological problems. moderate. such as medical file. John does indeed have a reading disability. Adjusting to a new school is usually a mild stressor. characterized primarily by problems in comprehension due to severe difficulties with working memory. Axis III: (Medical conditions that impact on the referral question. to protect the child due to extremely poor reality testing. if any. If it’s serious. Identify any educational interventions needed. so that emergency needs can be met immediately. Your first point. and/or additional or alternative ones pertinent to the referral questions. and less critical recommendations later in each numbered point. say so clearly. ) Axis IV: (Psychosocial stressors: list category of stressors and the specific stressors. 2. that can be implemented at home. with support. his comprehension are:) and then several ways to help improve or accommodate the difficulty. the code is “V71.XX in addition to their codes. or may be more severe if it comes as a result of some trauma.Child Name diagnosis. or pediatrician. because you are not qualified to make medical diagnoses. Note the source of the information. arranging them by problem area. 16 Axis I: XXX. Further. 2. My recommendations start with a numbered statement of the problem (E.. Suggestions to improve. 1. to take action to protect the child or others from the child’s dangerousness. etc. Group recommendations according to the major findings of the report. the referrer. or that the child/adolescent can work on themselves. full 5-axis diagnoses must be given. their family.09 No Diagnosis”. Failure to cite the source can leave you open to charges of practicing medicine without a license.

and urgency? To achieve what goals? Of what expected duration? If this is an inpatient assessment.” “John’s therapist should help him cope with the learned and habitual behavior patterns that accompany his ADHD.” “Individual. to address Mary’s adjustment to high school and separation anxiety is recommended. setting. outpatient. Identify whether psychological treatment is warranted. non-psychiatric interventions needed? What kind? By whom? Other agencies need to be involved? Example: “Given the nature of Mary’s cultural and religious beliefs and their impact on her parents’ willingness to seek therapy.) 3. as she is considering dropping out of school. intensity. is continued hospitalization warranted? Based on what? Example: “Continued inpatient hospitalization is warranted due to John’s suicidal ideation and plan. her parents should consult with her pediatrician or an adolescent psychiatrist to determine whether anti-anxiety mediation would help her calm down enough to attend classes while she is beginning therapy.” 4. related to what specific issues? What mode? What kind? What frequency.Child Name 17 3. or whether the rabbi can assist her and her parents in accepting the professional help she clearly needs. concurrent severe anxiety. and frustration tolerance. and specifically should focus on helping him develop impulse control.” . This consultation should identify whether the rabbi is capable of helping Mary with her depression. give contact information. consultation with their rabbi is recommended. Mary should begin working with the high school counselor this week if possible. Non-psychological. Specific attention should be paid to evaluating her sleep pattern. once weekly.” (If making a specific referral. lack of social support. Consider medical evaluation? To alleviate what symptoms? Example: “If Mary’s anxiety does not abate within two weeks of starting treatment. since she reports she stays up “all night” worrying.” “Mary 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. the capacity to delay gratification. and refusal to participate in outpatient therapy. If so. cognitive-behavioral therapy. and to receive support from others after having been “outed” at school.

Johnny should be switched to a position that minimizes interaction with customers. 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 John has suffered as a result of his substance abuse. Unless her parents can be helped to adopt a supportive yet adaptive approach. Issues that might interfere with treatment and how to address them? Example: 18 “Mary’s parents see her as a victim of “the high school’s impersonal.” They repeatedly sympathize with and encourage her distress. to reduce his anxiety and provide him with opportunities to check out his interpretation of his experiences. Rehabilitation evaluation is recommended to identify interventions that may help him cope with his impairments. this otherwise capable student may continue to struggle with the transition to high school. reassessment is recommended in one year to assess the efficacy of the new Individual Education Plan and to determine whether an alternative educational placement should be considered. It is recommended that her counselor arrange to meet with her parents and that they be encouraged to participate in the Parents-in-Transition outreach program.” “Given the nature of John’s learning disability and his slow progress despite the special education services he is receiving..” 7. Environmental interventions (e. He should have the opportunity to socialize with a small group of fellow workers.” “At work.Child Name 6. stimulus control) needed? Example: “Johnny needs to be seated at the front of each classroom. include a formal signature block.” Finally.” 8. which looks like this: . uncaring environment. so that he is able to see the board.g.

It is the absence of a credential. Psy. do not list A. highest EARNED and RELEVANT degree Examiner (or Psychology Intern. such as J. if you are a doctoral student in a program where I teach.e..D. varies from the path to the Ph. Degree Supervisor Ethical guidelines specify that you should list only your highest. Psy. If you are a diplomat (i. it is expressly prohibited to list yourself as “Psy. Traditionally. See the next pages for WJ-III results tables I use in my reports. Do not list your Ph. Because the path to the Psy.D. Do not list a bachelor’s degree.D.. That is..D.D. if you are one) First Last. Do not use it! Similarly. programs generally do not recognize or use the term. or R. you may add these initials to your degree initials. e. “John Smith. Candidate”.D. In addition. or even education (unless it’s school psychology). You can list masters’ level training in a related mental health field if you have not completed your doctorate in psychology. It is not..D.. the term is reserved for persons who have completed everything for the doctoral degree except for the dissertation. 19 ________________________________ ________________________ Your name.N. are irrelevant and not to be listed. Psy. have passed advanced competency board exams).Child Name Respectfully submitted. and whose dissertation proposals have been accepted.D.D. Your M. The public thinks this is a credential.B. English.. most programs do not use or endorse the term. . in economics. relevant degree (or two if both are relevant. ABPP”. if you practice mental health law).g. you cannot load your signature to make your credentials look more impressive.D. because that education did not train you to perform psychological testing/assessment.

Child Name Woodcock Johnson – III Cognitive Test Results Cluster/Test Thinking Ability Verbal Ability Comprehension-Knowledge General Information Verbal Comprehension Cognitive Efficiency Processing Speed Visual Matching Decision Speed Pair Cancellation Retrieval Fluency Working Memory Numbers Reversed Memory for Words Auditory Working Memory Long-Term Retrieval Visual-Auditory Learning Visual-Auditory Learning Delayed Retrieval Fluency Rapid Picture Naming Fluid Reasoning Concept Formation Analysis-Synthesis Cognitive Fluency Broad Attention Numbers Reversed Auditory Working Memory Pair Cancellation Executive Processes Concept Formation Pair Cancellation Visual-Spatial Processing Spatial Relations Picture Recognition Phonemic Awareness Sound Blending Incomplete Words %ile Standard Score Functioning Level Name the range 20 Z = .nn .

Oral Language 4. Listening Comprehension a. Math Reasoning a. Spelling of Sounds c. Story Recall – delayed c. Broad Written Language 6. Word Attack 2. Written Expression a. Applied Problems b. Basic Reading Skills a. Broad Reading 1.Child Name Woodcock-Johnson III Achievement Test Results Cluster/Test A.C7b. Math Fluency 10. C6a. Writing Fluency b. D9) 21 %ile Standard Score Functioning Level Name the range Z = . Calculation 9. Reading Fluency 3. Oral Expression a. Quantitative Concepts Academic Skills (A1a. Reading Vocabulary B. Basic Writing Skills a. Spelling b. D9) Academic Applications (A3a. Broad Math 8. Editing d. D8) Academic Fluency (A2. Oral Comprehension C. Picture Vocabulary 5. Letter/Word Identification b.nn Academic Knowledge Phonemic/Graphemic Knowledge Total Achievement . Reading Comprehension a. C7a. Passage Comprehension b. Understanding Directions b. Writing Samples D. Punctuation & Capitals 7. Story Recall b.