Psychological Evaluation Report

STRICTLY CONFIDENTIAL


Date:

IDENTIFYING DATA

Name:

Date of Birth: Gender:

Date of Testing:

Chronological Age:

Religious Affiliation:

Educational Status:

Home Address:

Telephone Number:


REASON FOR REFERRAL

BACKGROUND INFORMATION

Family

Personal


INSTRUMENTS ADMINISTERED

BEHAVIORAL OBSERVATIONS

TEST RESULTS AND INTERPRETATION

Intellectual Functioning

2
Emotional and Interpersonal Functioning

DIAGNOSIS

DIFFERENTIAL DIAGNOSIS


SUMMARY

RECOMMENDATIONS



Prepared by: