PSYCHOLOGICA

L ASSESSMENT
of Billy Smith

Anthony, Alexis

Mansfield University of Pennsylvania

Name: Billy Smith D.O.B.: 11/19/98
Address: 1389 Pike View Rd. Age: 19
Jacksonville, FL 32277 Sex: Male
Phone: 570-446-7891 Ethnicity: Caucasian
E-mail: billy.smith.18@aol.com Date of Interview: 04/16/18
Name of Interviewer: Alexis Anthony

Presenting Problem or Reason for Referral

The 19-year-old male was referred for a psychological assessment due to high levels of

stress, anxiety and depression. Billy, the client, reports to having both anxiety and depression in

the past, but lately is being more effected by the symptoms than usual. He states he also feels

angry and at times overwhelmed by his feelings. An assessment was conducted to further assist

and determine a diagnosis and recommended course of treatment.

Family Background

Mr. Smith was raised in Myerstown, PA. He grew up in a loving household; both parents

were active in his life. He described his Mom as the “typical mom”, or the caregiver. Although,

he said that she does not really have a sense of humor. The thing he remembers most about his

time with his Mom is watching every episode of American Idol with her at night when he was

growing up. He stated that his Dad worked second shift, so they spent a lot of time together after

school and what not. He stated that his Dad was the one who showed him how to be a man, how

to play baseball and gave him his sense of humor. While he was growing up, he said that his dad

was not an emotional person, but now, he is the most emotional person he knows.

He is not close to any extended family, including his half-sister, April. April is physically

handicapped with spina bifida, and is always in a wheelchair due to it. He stated that when they

were younger, they were very close. Although, when she got married to a man that Billy does not
like, their relationship fell apart. Billy said that she became ungrateful for what their Dad has

done for her. They went years without talking until this past year. They all gathered and talked

through things, although they are still not as close as they were when they were younger. He said

that he has not talked to her in a while, but knows he needs to call her.

Significant Medical/ Counseling History

Mr. Smith discussed the time he fractured his skull. When asked how this happened he

said that he jumped on the hood of a car, which the driver then proceeded to gas the vehicle up to

a speed of 30 mph. The driver then slammed on the breaks and launched Billy through the air,

the fall causing the fracture to the skull. He stated this was a very traumatizing time in not only

his life, but his friends and families as well because he/they thought he was going to die.

Miraculously, he recovered in almost little to no time.

Substance Use and Abuse

There was no sign of substance use and/or abuse with Mr. Smith.

Educational and Vocational History

Mr. Smith attended Eastern Lebanon Area School District until the 11th grade. He stated

that school was and in quotes, “Hell”. He was always an athlete, but never got the recognition

that he believes he deserved. When he got to the age of around 12, he gained some weight and

began to be bullied. He lost motivation to go to school and his grades suffered because of it.

Billy also stopped putting forth full effort into sports as he felt he did not receive what he was

putting into it.

 For his junior and senior year of high school, Mr. Smith attended a vocational

technological school, Lebanon County Career and Technology Center. There, he said he had a

much better experience. He stated that, that is where he met some of his best friends, and a girl

friend at that time.

Now, Mr. Smith attends Mansfield University. He said that he is happy here, and feels

more respected. He stated that he has a lot of friends, but only a small group that he truly trusts,

this not including his girlfriend although. At Mansfield, he is on the baseball team. However, he

is what is known as a “redshirt”, meaning he is almost guaranteed little to no playing time.

During the interview, he seemed on edge when this topic was brought up, but he did not address

it.

Other Pertinent Information

Mr. Smith came off as a very confident guy and appeared to show his dominance through

women. This meaning he was very open about his sex life. He discussed the number of women

he has slept with since just being at college. He also made a point to talk about when lost his

virginity. He was at the age of 14 and specifically acknowledged that the girl was the age of 18.

He stated that his dad was proud of him but it caused an issue on his baseball team because it

was his coaches daughter.

Billy Smith also discussed jumping around in the work force. He has worked at five plus

places. He has been at his current job for a little over a year, which is the longest he has ever held

a steady job according to his history shared.

A quote from Mr. Smith himself said, “I’ve experienced things in life that no one should

experience.” He stated that he feels like he has been through a lot, this majorly including loss of

many loved ones. He discussed many family members that he has lost, some include his uncle
and his grandfather. He also talked about losing his best friends brother in a car accident. Overall

though, he feels like he has had a "solid” life.

Mental Status

Mr. Smith was averagely groomed. He was dressed in an everyday attire; sweatshirt, knee

length shorts and sneakers. He seemed confident and comfortable talking the entire time. He

seemed to be in a rush to end the session at first, but when he began talking, he completely lost

track of time. Some questions that were asked he talked for over ten minutes.

Assessment Results

Test Used: Stress Test, Procrastination Test, State-Trait Anxiety Inventory, Beck Depression

Inventory and Emotional IQ Test

Mr. Smith obtained a Stress Test score of 67. This places him on the higher side of the

scale, i.e. above average. On the Procrastination Test, he scored a 59. Again, this is on the higher

side of the scale, so another above average score. For the State-Trait Anxiety Inventory, he scores

a 35. Again, an above average score. The Beck Depression Inventory, Mr. Smith received a score

of 12. This meaning that he indicates minimal depression. Finally, the Emotional IQ Test, he

received a 112. This score also lands on the higher side of the scale.

Diagnosis

Axis I: Mild to Severe Anxiety and Depression and High Levels of Stress

Axis II: Mild Narcissistic Personality Disorder

Axis III: No diagnosis

Axis IV: Discontent with job; Material discontent

 Axis V: GAF = 57

Summary and Conclusions

Mr. Billy Smith is a 19-year-old male referred for depression and anxiety. He is from

Myerstown, PA, but he now lives in Florida. He had a very loving family, and a close

relationship with both of his parents. He attended two schools throughout his lower level

education, Eastern Lebanon Area School District and Lebanon County Career and Technology

Center. He currently is attending his first year at Mansfield University with a major in education,

specializing in history (originally a major in psychology).

Mr. Smith has lived a moderately regular life. He stated that he has experienced a lot, but

still has had what he called a “solid” life. Other than experiencing some bad things, mainly

death, he has had a steady love life, and is very confident in his sexuality. He is currently in a

committed relationship with his girlfriend of a few months. Although, through the interview, he

said that he still cannot trust her.

During the interview, Billy was adequately groomed and seemed comfortable and

confident in himself and his responses. He was not shy about anything and willing to talk for a

while. He answered every question with little to no hesitation and had full openness. Some of the

responses seemed far-fetched, or embellished on his part. Many of these adjustments to his

stories seemed to work in his favor to contribute to him.

Mr. Smith’s results for the test used to help along with his evolution most definitely

mimicked a pattern. He landed on the high end of every scale, minus the depression test. This

went along with his referral, and provided more evidence toward is diagnosis. Overall, Mr. Billy
Smith appears to have mild to severe anxiety, depression and is stressed out. These are returning

symptoms as well as new ones. He is a current college freshman, with a lot on his plate. He is

bound to be experiencing many feelings like these, many due to a lot of sudden change. Also,

scoring high on the procrastination test shows that he more likely then not, puts work off and that

is not helping, but adding to the stress.

On a positive note, Billy seems to be hitting a point in his life where he is flourishing and

becoming a man. He is maturing thanks to entering a new environment, and having a girl friend

is helping in many ways. She is allowing him to build trust for more than just a few people and

controlling his actions by not allowing his ego to get the best of him and/or his actions.

Recommendations

1. Counseling, 2 hours a week for depression and/or anxiety.

2. Referral to physician/psychiatrist for medication, recommendation of

antidepressants.

3. Adjust time management to reduce stress levels.

X_______________________________
Anthony, Alexis