Clinical Assessment Report CONFIDENTIAL

IDENTIFYING INFORMATION

Patient Name : Gian Louie Mateo

Date of Birth : November 10, 1999
Age : 21 years
Sex : Male
Civil Status : Single
Address : National Road Wakas, Orion, Bataan
Contact Number : 09194494100
Occupation : Student
Education : 15 years
Handedness : Right
Examiner : Gian Louie N. Mateo
Date of Evaluation : January 2, 2021

REASON FOR REFERRAL

Mr. Louie was referred by Dr. Rachel Laureano. for concerns about interpersonal
relationships, workstyle and psycho-emotional functioning

ASSESSMENT METHODS

MYERS-BRIGGS TYPE INDICATOR (MBTI)

Date of administration: December 9, 2020

Myers-Briggs Type Indicator (MBTI) is a self-help assessment test that helps people
gain insights about how they work and learn. It is a framework for relationship-
building, developing positivism, and achieving excellence.

THE BIG FIVE TEST OF PERSONALITY

Date of administration: December 19, 2020

You'll see how you stack up on five significant dimensions of personality: Openness,
Conscientiousness, Agreeableness, Extraversion, and Neuroticism. The Big Five Test of
Personality is widely considered the most robust way to describe personality
differences.
INVENTORY OF INTERPERSONAL PROBLEM

Date of administration: December 19, 2020

The Inventory of Interpersonal Problems (IIP) is a self-report instrument that identifies

a person's most salient interpersonal difficulties. Understanding and resolving
interpersonal problems is considered an essential step for alleviating common
symptoms and syndromes, including depression and anxiety.

THEMATIC APPERCEPTION TEST

Date of administration: January 02, 2021

A projective test designed to reveal a person's social drives or needs by their

interpretation of a series of pictures of emotionally ambiguous situations.

SACK'S SENTENCE COMPLETION TEST

Date of administration: December 29, 2020

The Sacks Sentence Completion Test (SSCT) is a 60-item test that asks respondents to
complete 60 questions. The first thing that comes to mind across four areas: Family,
Sex, Interpersonal, Relationships, and self-concept.

*see details here

BACKGROUND INFORMATION

Gian Louie N. Mateo is a 21 years old man that resides at Wakas, Orion Bataan.
He's the observant one in his family. The members of their family are the
breadwinners of the family. He's always a shy, cheerful, and decent boy that always
play in his childhood. But as he grows up, he became neutral and always afraid. His
parent's way of disciplining their child is through negative reinforcement and using
punishment. There was a time when he does something wrong, his mother became
furious, and Louie leaves their house.

During his toddler years, he became a victim of maltreatment. His nanny used
to smear calamansi juice, topical ointment, and even soap to his eyes. At the young
age of 7 years old, his parents always remind him that he is an adult; he treats himself
as an adult at 7.

During his puberty period, he thinks that he can do almost anything and feels
that he's independent in his ways. He always finds himself doing an adventure, and it
is therapeutic for him because he can feel freedom.
 Going on to his late adulthood, he almost spends his time on organizations, mostly
in groups, because he doesn't feel at home. He became part of different leadership
organizations because he thinks that somehow, he is powerful but in a good way. But
he admits that he lacks emotional support. This is because of his childhood.

 PAST MEDICAL, NEUROLOGICAL, PSYCHIATRIC, SUBSTANCE USE

HISTORY
Past medical history is tonsillectomy - surgical removal of the tonsils, two oval-
shaped pads of tissue at the back of the throat — one tonsil on each side i n 2007,
activity-induced tonsillitis. In 2008, due to maltreatment during his toddler year, Louie
was diagnosed with a combination of astigmatism and nearsightedness. Instead of
being focused precisely on your retina, light is focused in front of your retina, making
distant objects seem blurry. In 2015, Louie was diagnosed with Allergic Rhinitis - also
known as hay fever, is a type of inflammation in the nose that occurs when the immune
system overreacts to allergens in the air.

There is no psychiatric history, and substance use history was reported above.

 BIRTH, DEVELOPMENTAL, OCCUPATIONAL HISTORY

(Review of perinatal factors, early childhood development, milestones, academic history and
achievement, employment). Louie denied any problems with her birth or development.
He said math and chemistry skills were always a relative weakness for her in school,
but she was never diagnosed with a learning disability. He completed high school and
started college immediately after high school, but during his Senior Highschool year,
he chose the wrong decision to take a HUMSS strand because of the counselor's
misleading information. His first choice is Civil Engineering, but eventually, his
curiosity to people, he chose to take a Psychology course. Subsequently, He became
part of different leadership organizations, pursued his dream to be a singer, joined a
school choir, and competed internationally. He is a student-leader and spends most of
his time making papers and making connections to other people through making an
event.

 FAMILY HISTORY
(First-degree relatives; only pertinent features reported). He came to Mateo Family, His
father is Luis N. Mateo, OFW. His mother is Angelina N. Mateo, Business owner. He
has an elder brother named Angelou N. Mateo, Engineer. His parents and brother are
considered as "Breadwinners" of the family. This became his motivation. He stated
that he would make his family proud of him one day no matter what and prove
himself.
  PSYCHOSOCIAL HISTORY AND CURRENT ADAPTATION
(Current living situation, social relationships, activities of daily living) Louie is single
and lives with his parents. He remains fully independent in all activities of daily
living. She stated her hobbies tend to focus on physically demanding activities such as
exercising or working out. He also said he enjoys riding his bike and has an extensive
network of social support.

TEST RESULTS AND INTERPRETATION

Myers-Brigg's Type Indicator

TYPE SCORE
Introvert 6
Intuition 11
Feeling 16
Judging 16

THE BIG FIVE TEST OF PERSONALITY

TRAIT SCORE INTERPRETATION
Extraversion 23 MODERATE
Agreeableness 33 HIGH
Conscientiousness 28 MODERATE
Neuroticism 21 MODERATE
Openness to Experience 32 HIGH

INVENTORY OF INTERPERSONAL PROBLEMS

  Z-SCORE INTERPRETATION
Domineering (PA) 2.69 VERY HIGH
Vindictive (BC) 2.49 HIGH
Cold (DE) 2.25 VERY HIGH
Socially Avoidant (FG) -0.61 AVERAGE
Nonassertive (HI) -0.56 AVERAGE
Exploitable (JK) -1.47 VERY LOW
Overly Nurturant(LM) -0.95 AVERAGE
Intrusive (NO) -0.56 AVERAGE

A. Interpersonal Relationships
 Louie's scores on interpersonal relationships were variable but generally within
at least the average range. He tends to be very social or in a group but there is a
specific time to work alone. It is seen in the IIP he has a very high Cold trait but
average on Socially Avoidant trait. Louie would like to be approached by another
person; than he is going to come to them. It is further reinforced by high scores in
Agreeableness and his INFJ type, which are concerned for people's feelings and try to
be gentle to avoid hurting anyone because they're a natural nurturer.

It is found that he has a very high domineering trait, but in good way, he's
always striving for achievement and tend to be determined and goal-driven (need for
power) This desire is further reinforced by having a family member that are
breadwinners and serves as a model to him. (Observational Learning) The desire to be
like them is being satisfied by leading other people and always achieving. This also
shows his motives in Thematic Apperception Test

In general, Louie is a deeply warm and caring person who is highly invested in
the health of their close relationships and puts forth a lot of effort to make them
positive. They are valued by those close to them for these unique qualities. He seeks
long-term, lifelong relationships.

B. Workstyle
Louie's scores on Openness to Experience are high, and he might be more
flexible, curious, and adventurous when it comes to working. There is a high
possibility that he performs his task effectively, it is because he mentioned in his
background that he wants always to achieve something. His Conscientiousness scores
are relatively moderate, a personality trait that reflects the degree to which a person is
dependable, responsible, perseverant, and achievement-driven. He also marked high
in Agreeable Trait, and tend to perform well in jobs requiring interpersonal
interactions such as customer service, and generally do well in teams. The INFJ usually
shows up in areas where they can be creative and somewhat independent.

On the other side, He has a moderate score on Neuroticism, there is a tendency

to be more emotionally stable and less reactive to stress, but there is also a tendency to
have high emotional reactions to stress depending on a situation. Being an Agreeable
person, he's likely to be attracted to "social" professions that are emotionally
demanding (for example, nursing, and counseling) and have high burnout rates.
Proper, stress-management will lessen the stress.

In general, Louie has a natural affinity for art and may excel in the sciences,
where he can use his intuition. Being an INFJ, he can also be found in service-oriented
professions. They are not good at dealing with minutiae or very detailed tasks but in
very flexible and independent work. He knows what he does when in the workplace
 and takes every task seriously because he has a very low score of being Exploitable.
All in all, he works efficiently and effectively.

C. Psycho-emotional Functioning

This information was gathered through hand-in-hand interview and several

personality tests he had taken, including MBTI, The Big Five Test of Personality, and
IIP.

Looking through his MBTI type, as an INFJ, his primary mode of living is
focused internally, where he might take things primarily via intuition. Most INFJ's are
protective of their inner selves, sharing only what they choose to share when they
choose to share it. They are deep, complex individuals who are quite private and
typically difficult to understand. INFJ's hold back part of themselves and can be
secretive. This further reinforced by a very high score to the Cold trait in IIP.

Louie has a moderate score on Neuroticism and tend to be more emotionally

stable and less reactive to stress but there is also a tendency to have high emotional
reactions to stress depending on a situation.

CONCEPTUALIZATION AND CLASSIFICATION

Multiple methods of assessment and sources of data inform the conceptualization of

Louie’s Interpersonal Relationship, Workstyle and Psycho-emotional functioning.

Louie’s overall interpersonal relationship is variable, (MBTI – 6; Introvert), According

to Inventory of Interpersonal Problem, Louie’s being Socially Avoidant is average.
Louie also marks average on his extraversion trait (TBFTP = 23; Extraversion). It is seen
that Domineering (IIP- PA), Cold trait (IIP-DE), Vindictive (IIP-BC) of Louie is
relatively high It is possible that Louie can tends to be more social if he’s with close
friends. It is observed that he's overly nurturant to close others but there's a tendency
to be vindictive and domineering to individuals who are not close to them, or he
considered a threat. His primary mode of living is focused internally as seen the
assessment.

According to the Big Five Test of Personality result, (Conscientiousness = 28;

Moderate), (Neuroticism = 21; Moderate). Louie's scores on Openness to Experience
(32 = High) are high. He also scores very low on Exploitable trait (IIP-JK = 1.47). There
is a high possibility that he performs his task effectively. And according to the interv
SUMMARY

The purpose of this evaluation was solely to evaluate Gian Louie N. Mateo's
Interpersonal, Workstyle, and Psycho-emotional. In line with this, I performed a series
of tests and interviews to assess Louie's background and history.

Louie's scores on interpersonal relationships were variable but generally within

at the least average range. It is observed that he's overly nurturant to close others, but
there's a tendency to be vindictive to individuals who are not close to them, or he is
considered a threat. It is also found that he has a very high domineering trait; he's
always striving for achievement and tend to be determined and goal-driven. Louie is a
deeply warm and caring person who is highly invested in the health of their close
relationships and puts forth a lot of effort to make them positive.

He has a high score on the Conscientiousness trait in his workstyle and is

described as an efficient and effective member and a team player. This also indicates
his good interpersonal function. Louie has a moderate score on Neuroticism and tends
to be more emotionally stable and less reactive to stress. His Openness to Experience
scores is relatively high, and he tends to be more creative, flexible, curious, and
adventurous when it comes to working.

The psycho-emotional functioning of Louie is focused on the self. Looking to his

MBTI type, as an INFJ, his primary mode of living is focused internally, where he
might take things primarily via intuition but has Extraverted Feeling. Often called as
Extroverted Introverts.

Louie's strength is being a natural leader, warm-hearted, sensitive, and

compassionate towards people, passionate, artistic, curious, and value deep, authentic
relationships. These characteristics help him build up his confidence. However, he also
possesses some weaknesses that might need some improvement. Some are being
unpredictable in some instances due to his cold personality and difficulty leaving a
bad relationship.

RECOMMENDATION

Based on the evaluation presented, the following recommendations are given:

1. The test findings also showed that he has a high domineering and cold personality
trait. Both should manage well to avoid mishaps or any problems in interacting.
2. The assessment finds out Louie has a moderate score on Neuroticism and tends to
be more emotionally stable and less reactive to stress depending on situation.
Proper, stress-management is recommended.
3. Work on one task at a time until completed. Try to minimize multitasking
environments.
4. Needs to focus on applying their judgment to things only after they have gone
through their intuition.
5. Try to be on good terms with all people, even those that consider beneath. Try to
understand that everybody has something to offer.
6. Upon observation in Sack’s Sentence Completion Test, when upset, walk away
immediately. Don’t express anger when gets angry. After having to calmed down,
apologize for leaving and continue with what you were doing.

Mr. Gian Louie N. Mateo is welcome to schedule a follow-up one-hour appointment

to review and discuss the results of this evaluation.

Psychologist