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A Smith Psychological Evaluation Confidential
Name: irthdate: Age: (ender: Education: *e+ort ,riter: -ate of re+ort: /nstruments Administered: Clinical intervie0
Case Number !ctober "#$ "%&' "# years$ ' months )emale %th grade November .$ .''5
*eason )or *eferral Ms. A. Smith is a "#1year1old African1American female 0ho 0as referred for a +sychological evaluation as +art of a -iagnostic Assessment Class at Clar2 Atlanta 3niversity$ Atlanta$ (a. She +resented as a 0ell1nourished female of average height and 0eight. 4er hygiene and grooming seemed ade5uate. No unusual behaviors 0ere observed and she did not demonstrate any difficulty moving about the evaluation site. 6he Ms. A. Smith +rovided the follo0ing information. Ms. Smith 0as born in Connecticut and is an only child. 4er +arents never married and +rimarily her mother$ Ms. Smith$ reared Ms. Smith. She re+orted that she did not 2no0 much about his biological father. Ms. Smith 0as the +roduct of a full term uncom+licated birth. No history of head trauma 0as re+orted. Ms. Smith7s mother re+orted that sexual abuse 0as sus+ected 0hen Ms. Smith 0as in daycare$ 8it 0as investigated but never +roven.8 No history of health +roblems 0as re+orted. No medications are currently +rescribed. Educational 4istory Ms. Smith began school at the ex+ected time. 4er mother re+orted that she demonstrated behavioral +roblem beginning in daycare$ 8she had +roblems 0ith authority even then.8 She re+eated 2indergarten because 8her teachers thought that she 0as not mature enough to be +romoted to the first grade.8 Ms. Smith mother re+orted that her daughter 8 has al0ays had +roblems 0ith teachers and being told 0hat to do.8 Ms. Smith7s mother re+orted that at "" years of age$ Ms. Smith began staying out late and 8hanging out 0ith undesirables.8 ,hen she 0as "" she 0as arrested 0hen the +olice raided a house for drugs. 4er mother stated that Ms. Smith 0as almost ra+ed once$ but this 0as never confirmed. After the arrest Ms. Smith 0as +laced in a residential facility. She 0as there for one and one1half years. 6he family moved from Connecticut to California9 they
.Psychological Examination Ms. / have outbursts. No history of being diagnosed as having an attention deficit disorder 0as re+orted. No other drug use 0as re+orted. Smith and her mother moved to (eorgia in "%%5. Ms. Smith 0as charged 0ith ?iolation of Probation and 0as ordered to +artici+ate in intensive .$ "%%#$ and on >uly . She began using mari. Smith 0as +laced in classes for the learning disabled. Ms.uana usage 0as re+orted because of her being incarcerated. Ms.uana. Smith denied having a history of health +roblems. Smith re+orted that she began ex+erimenting 0ith alcohol at the age of ". 4ealth 4istory Ms. Ms. She re+orted that her alcoholic use 0as s+oradic. Smith 0as charged 0ith ?iolation of Probation. Since moving to (eorgia Ms. She denied having a history of intoxication due to alcohol use. =egal 4istory 4er initial contact 0ith the >uvenile Court 0as in A+ril "%%5$ 0hen she 0as charged 0ith ma2ing 6errorist 6hreats.hen as2ed about her behavior Ms.8 4er mother also re+orted that she is in counseling and this has hel+ed their relationshi+.8 .hile on +robation she 0as charged again 0ith *unning A0ay on August "%%5. My attitude has changed since being her$ but / don7t 2no0 0hy. Smith to return home and a de+rivation charge 0as filed. / have been having these outbursts since / 0as "<. . Smith 0as +laced in classes for the behavioral disordered. Substance Abuse 4istory Ms. Smith re+orted 8/ have a tem+er that / need to control.uana about once a month and she has been intoxicated five to six times smo2ing mari. Smith re+orted that she smo2es less than a +ac2 of cigarettes a day.hile involved in intensive +robation$ Ms. Smith 0as ordered to serve <5 to #' days in a youth develo+ment center for using fighting$ vulgar language$ and harassing +hone calls. Smith 0as again charged 0ith ?iolation of Probation again on >uly ".uana at the age of "<. She admitted smo2ing mari. A Smith Page 5 0ere there only nine months. 6hat charge 0as dismissed. Smith 0as charged 0ith *un A0ay and ungovernable behavior. 4er mother refused to allo0 Ms. Currently$ Ms. Smith7s mother is currently unem+loyed. Since being at this facility her mother re+orted$ 8Ms. /n the ninth grade$ Ms. No current mari.8 Ms.< months +robation. /n A+ril "%%# Ms. Smith has been good 0hile at this facility. /n >anuary "%%#$ Ms..hen / get angry / cuss a lot. /n May "%%5$ Ms. Smith 0as +laced on ". months +robation and tem+orary custody 0as granted to the -e+artment of )amily and Children Services for "& months. Smith is a ninth grade student at a high school in -e:alb County$ (eorgia. . 8She did !: 0hile 0e 0ere in California.<$ "%%#. .
She denied having feelings that others can read her mind or that she can broadcast her thoughts to others. She had a deliberate style of ans0ering and 0or2ing on most +roblems. 4er gait and +osture 0ere normal. She 0as casually dressed and her hygiene seemed ade5uate. No unusual behavior 0as observed. Ms. A Smith Page 5 Mental Status Examination Ms. )idgeting or difficulties remaining seated 0ere not noted. Attention and effort 0ere age a++ro+riate.Psychological Examination Ms. 4er activity level 0as observed to be 0ithin normal limits for age range. Ms. Most 0or2 0as com+leted 0ith an orderly +lan and self1correction. 4er a++earance and grooming 0ere ade5uate and a++ro+riate. Ms. /n general$ the obtained results are considered a valid and reliable sam+le of her +ercent level of functioning. Smith +resented as a 0ell1nourished female of average height @57A8B and 0eight @""5 +oundsB body build. Smith7s s+eech 0as relatively clear9 at times she mumbled 0hen she s+o2e 0hich made her res+onses difficult to understand at times. *a++ort 0as easily established and maintained. . Ms. Motivation to succeed and +erform 0ell a++eared to be ade5uate. Neither disru+tiveness nor difficulty in coo+eration and com+liance 0ere noted during the evaluation. Signs of im+ulsivity or carelessness 0ere not observed. 4er thoughts 0ere organiCed and coherent. Smith denied having any s+ecific +hobias$ obsessions$ or com+ulsions.usting or res+onding a++ro+riately$ and no signs of emotional reactions or unex+ected errors on early items. Smith re+orted that she has a tem+er and admits that anger is a +roblem for her. *e+etition and em+hasis 0ere not needed. ehavior !bservations Ms. She made an ade5uate effort on most tas2s$ and reacted to failure 0ithout clear frustration or rene0ed effort. She a++eared her stated age. . . Smith re+orted that she felt ha++y and +layful most of the time. She demonstrated limited insight into her +roblems and her .udgment seemed ade5uate. She denied having +roblems concentrating. No histories of auditory or visual hallucinations 0ere re+orted. Ms. Smith a++roached the testing session in a coo+erative and friendly manner. !verall$ she did not +resent as having a thought disorder nor did she +resent as being a danger to herself or others. /nstructions 0ere follo0ed carefully and understood 0ithout a++arent difficulty.hen as2ed about her mood Ms.hen ne0 tas2s or ne0 instructions 0ere +resented$ there 0as no difficulty ad. 4er attention and concentration 0ere age1a++ro+riate and her immediate$ recent$ and remote memory seemed intact. She denied having +ast or +resent thoughts of harming herself or others. *es+onses 0ere usually made in a reflective$ thoughtful manner. Smith did not engage readily in s+ontaneous verbal ex+ression$ and had to be +rom+ted or urged to elaborate on brief res+onses. Smith a++ears to be functioning in the Average range of intellectual abilities.
. Smith and develo+ more a++ro+riate and functional inter+ersonal +roblem1solving s2ills.& Conduct -isorder$ Adolescent onset ty+e$ moderate. *ecommendations ".#' Cannabis Abuse A". Smith7s mother develo+ more a++ro+riate strategies to manage her behavior in the community$ if and 0hen a return to home is considered A.. 4e seems motivated to 0or2$ but her vocational choices are vague.. /ndividual thera+y$ in addition to grou+ thera+y$ 0ill be needed to hel+ Ms.ustice system in her birth state$ Connecticut. Smith may benefit from involvement in a substance abuse +sycho educational grou+. <.. A +rogram that re5uires and fosters interde+endence and coo+erative 0or2 is +referred.' Parent1Child *elational Problem Axis //: ?E".riter . Ms.Psychological Examination Ms. Ms.A' /m+ulse Control -isorder$ Not !ther0ise S+ecified. Smith has a history of involvement 0ith the . 6he -e+artment of Children and Douth Services for violation of +robation +laced Ms. Com+liance to social standards and +robation ex+ectations must be em+hasiCed firmly and consistently.ustice system as 0ell as the . )amily thera+y 0ill be needed to hel+ Ms.. Additionally$ she may be a good candidate for a ?ocational *ehabilitation assessment. A'5. 4er most recent arrest 0as for sho+lifting$ running a0ay from home$ and violation of +robation.uvenile .'% No -iagnosis on Axis // Axis ///: None Axis /?: None Axis ?: E'. A Smith Page 5 Summary Ms. ?#". -iagnostic /m+ressions 1 -SM1/? Axis /:A". Ms. Smith at this facility. Smith is a "#1year1old African American female 0ho is currently housed at Another Chance Children7s Center. Smith 0ill re5uire a 0ell1su+ervised residential +rogram. *es+ectfully submitted$ FFFFFFFFFFFFFFFFFFFFFFFFFFFF *e+ort .uvenile . Periods of detainment may be needed to reinforce com+liance and a++ro+riate behavior.
A Smith Page 5 .Psychological Examination Ms.
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