ABC XYZ

PSYCHOLOGICAL EVALUATION FOR THE OFFICE

1234 STREET
CITY, STATE ZIP CODE
Phone NUMBER

Evaluation Date: xx/xx/2018

IDENTIFYING INFORMATION:

Name: ABC XYZ Case Number: NUMBER

Date of Birth: XX/XX/XXXX Address: 123 STREET CITY, STATE ZIP CODE
Chronological Age: XX years, XX months Phone: (NUMBER)
Gender: GENDER

Education: Will start 12th grade at HIGH SCHOOL this coming school year
Religious Status: None reported
Relationship Status: Seeing his current girlfriend for the past three to four weeks
Current Family Members: MOTHER, her boyfriend, two stepbrothers, a half-brother (who is also
ABC’s uncle, as grandparents adopted him from biological mother), maternal uncle, and two cousins
Nonresidential Significant Family Members: biological brother lives in STATE (biological mother’s
grandfather’s sister adopted him)

System Involvement: None reported

Primary Care Physician: Unknown
Psychiatrist: No longer sees one
Medication Regimen: Presently takes unknown “supplements;” previously took Risperdal, Tegretol,
Adderall, and Strattera
Community Involvement: None reported
Referral Source: OFFICE
Evaluator: Joshua Gonsher, M.A., M.S. Ed., Doctoral Intern
Supervising Psychologist: Michael J. Greisler, Psy.D., L.C.S.W.

REASON FOR REFERRAL:

ABC XYZ is a 17-year-old male who was referred for this psychological evaluation by the OFFICE to
assess his current emotional and cognitive functioning, specifically focusing on issues related to reality
testing and processing deficits. The results of this testing will assist ABC in determining which career
path would suit him best.

METHODS UTILIZED:
Clinical Interview
Wechsler Adult Intelligence Scale – Fourth Edition (WAIS-IV)
Wechsler Individual Achievement Test – Third Edition (WIAT-III)
Purdue Pegboard Test
Career Ability Placement Survey (CAPS)
Career Occupational Preference System (COPS)

This information has been disclosed to you from records of clients whose confidentiality is
protected by State Statute. State regulations limit your right to make further disclosure of this
information without prior written consent of the person to whom it pertains.
 ABC XYZ 2
DOB: XX/XX/XXXX
Sentence Completion Series: Work Form
House-Tree-Person Projective Drawing Technique (H-T-P)

RELEVANT HISTORY:

Development: ABC stated that he might not know or remember the answers to many of the questions
asked of him, but that he would try to the best of his abilities. He reported that his mother experienced a
normal, full-term pregnancy, and vaginal delivery. ABC related that he had trouble breathing from birth
until he turned two and that his mother had to “pat [him] on the back” to get him to breathe. ABC further
stated that he met all developmental milestones within normal limits but had difficulty with enuresis until
he was 11 years old. No significant trauma history was reported, and no other significant developmental
or medical history was noted.

School: ABC reported not knowing if he went to preschool, stating that he had to start late because of his
birthday but that he attended ELEMENTARY SCHOOL. ABC will be a 12th-grade student, enrolled at
HIGH SCHOOL, when school begins again at the end of August. Before being convicted of harassment in
11th grade, ABC was reported to have earned nothing lower than a C; however, with being “locked up”
(not known where), he missed educational opportunities that interrupted his progress and failed
Vocational Technology (VoTech) in school.

ABC said that he was “good at math but not so much at English or science, the two classes [he has]
always hated.” Additionally, he stated that he got along well with his teachers but two of them he “hated
with a burning passion;” one was reportedly loud and the other a “moron.” He said he has an
Individualized Education Program (IEP) for his math learning disability, which, along with behavioral
issues (see Mental Health and Medical History section), explains his enrollment in CHARTER SCHOOL
beginning in the 7thgrade and lasting until his legal involvement in 11th grade; additionally, ABC reported
that his handwriting is “complete and utter trash.” Though ABC does not know what specific career he
will pursue after school, he has expressed interest in “high-voltage electronics and computer
programming.”

Work: ABC indicated that he does not currently hold a job nor has he held one in the past.

Family and Social: ABC lives with his biological mother and her boyfriend; his two stepbrothers, one
younger and one older; his half-brother, who is also his uncle, as his grandparents adopted him from his
biological mother; and his maternal uncle and his two children, ABC’s two cousins, who are 14 and 15,
respectively. He reported getting along relatively well with “a whole house full” and that he feels as
though his mother loves him. ABC also stated that though they live in a four-bedroom house, the nine
people present add to its being “crowded.” ABC further said that he and his 14-year-old cousin argue
frequently since his cousin does not get into trouble for the same infraction that would lead to ABC being
reprimanded. Additionally, ABC indicated that his adolescent cousins constantly bicker and often try to
“kill each other.” ABC explained that they do not actually attempt to end each other’s lives, but they often
yell at each other and argue animatedly.

ABC said that his biological father left when he was two years old, and his mother primarily raised him.
Despite ABC’s many failed attempts to contact him over the past 15 years, he had not seen his father
since approximately a year ago, when he was reported to have given him a $3,000 home theater system
for his 17th birthday. ABC stated that he knew where his father was the entire time he was away and

This information has been disclosed to you from records of clients whose confidentiality is
protected by State Statute. State regulations limit your right to make further disclosure of this
information without prior written consent of the person to whom it pertains.
 ABC XYZ 3
DOB: XX/XX/XXXX
whenever he tried reaching him, his father did not respond. Nevertheless, ABC retorted that he “didn’t
give a shit. I got I wanted out of it, so why would I care?” When questioned as to why his father left, ABC
stated that no one would “never know which [side’s story] is true,” as both parents are reported to have
said that the other stopped talking to them. ABC said that his mother has been with her current boyfriend
for approximately five to six years, though “she’ll never get married” since “that’s just the way she is.”
She is reported never to have married ABC’s father, which explains why her last name, Custer, is
different from ABC’s.

ABC endorsed the presence of physical abuse by one of his mother’s former boyfriends but indicated that
these incidents of his “smacking [ABC] across the top of [his] head” happened approximately 12 years
ago. ABC stated his mother’s partner, the person who raised him, was on drugs at the time but has since
become “clean” and no longer uses drugs. He did not, however, endorse the presence of any emotional or
sexual abuse. Additionally, ABC stated that he has never incurred any trauma, saying that he is “not really
a scared person” and that he has an “I-don’t-care attitude.”

ABC stated that his siblings are not married and that his biological brother and his partner are “together
and then not together.” Additionally, ABC reported that his uncle/half-brother, BROTHER, and women
“don’t go well together” and that he “makes too much money to care about women.” ABC indicated that
“they screw him over” and that BROTHER does not pay attention to them. Finally, ABC said that he and
his current girlfriend have been together for approximately three to four weeks, that he has no children,
and that he has no plans to have them: “I’m short tempered; couldn’t do kids.”

ABC reported that before he and his mother moved into their current living situation they were alone
living in a trailer. Now that his mother’s boyfriend “drives trucks over the road,” they are reported to have
saved up enough money to buy a house and a new 2014 CAR. Additionally, ABC stated that his mother is
“medically disabled” and receives social security insurance (SSI) and social security disability insurance
(SSDI).

Mental Health and Medical History: ABC reported being hospitalized for “sexually acting out” when
he was “real little,” approximately between six and 10 years old though he stated he does not remember
exactly what happened.

ABC stated that he has been diagnosed with Tourette’s syndrome, in remission; “ADD (Attention-Deficit
Disorder) and ADHD (Attention-Deficit/Hyperactivity Disorder);” Asperger’s disorder, Oppositional
Defiant Disorder (ODD), and a learning disability in math. ABC indicated there were “probably a bunch
more,” but these were diagnoses he could remember. Additionally, ABC said that THERAPIST, a mobile
therapist from HOSPITAL, comes to his house to provide services.

ABC did not endorse the presence of any current suicidal ideation, intent, plan, or attempts though he
stated he had thoughts that he would be better off dead approximately two to three years ago. At that time,
ABC said that the thoughts came “randomly, every once in a while” when he felt bothered by his mother.
Additionally, while ABC said he had previously cut “not very deep” with a knife, which was reported to
have taken two weeks to heal, he stated he had “no idea” why, saying that it was “just kinda one of those
things.” ABC said that he is not suicidal but that he likes pain “for whatever reason.” He also did not
indicate the presence of any current homicidal ideation, intent, plan or attempts but that he has hit the wall
instead of his cousin when he was angry with him.

This information has been disclosed to you from records of clients whose confidentiality is
protected by State Statute. State regulations limit your right to make further disclosure of this
information without prior written consent of the person to whom it pertains.
 ABC XYZ 4
DOB: XX/XX/XXXX
Substance Use: ABC reported having smoked marijuana in the past but denies any current use, as he
stated his mother would “have [his] throat. [His] head would be in the front yard on a stick with a sign in
front of it ‘Don’t smoke weed’.” He indicated that his last use was approximately one and a half months
before he was put on probation due to a harassment conviction (see below), in June 2018. Additionally, he
stated that caffeine is his “friend” and that he does not “drink enough” of it. ABC also indicated that he
“sadly” smokes cigarettes, from one to two on average daily, but he said it can reach up to a half of a pack
if he is having a “bad day.” Finally, ABC stated that he has drunk alcohol in the past “to get drunk and
that was it” but that he “maybe” has not drunk since September or October of 2017. When asked what he
consumed at that time, he answered “Vodka, Jager, whiskey…Everything you can that’s strong. No less
than 70 proof. What teenager doesn’t do that nowadays?”

Legal Involvement: ABC was arrested in the 11th grade due to his allegedly raping a female student.
However, these charges were dropped to harassment. He stated that he had never been involved with the
law prior to this situation. However, ABC related a story when he was assaulted at school (i.e., reportedly
punched in the face three times) because the assailant misheard ABC refer to him by a racial slur. The
attacker then “lied to the courts” to get ABC in trouble.

Social History and Community Involvement: Socially, ABC’s behavioral issues greatly increased in
the 11th grade when he reported being accused of raping a girl and was “locked up for eight weeks” even
though he stated that the victim fabricated “half of the story.” ABC conveyed that he has “good friends,
bad friends, and then I have the middle. My good friends don’t drink, the middle friends know the
difference between good and evil, and my bad friends know the difference, but they don’t care.”

ABC stated he gets along with his friends and has never been bullied. He also said he enjoys participating
in age-appropriate activities, such as playing video games, riding off-road vehicles, and listening to music
that is in line with his moral values.

Psychiatric Medication History: ABC said that he had been on multiple medications including
Risperdal (2 mg/daily or twice), Tegretol (20 – 40 mg/daily), Adderall (100 mg), and Strattera. However,
he stated that the Tegretol gave him seizures, so he no longer takes that. ABC also said that he no longer
takes his other medications since he sees a “nutritional advisor” for supplements and that “it’s helping.”
He further indicated that he had to see a doctor for an EEG, an MRI, and special blood work and that they
discovered “two voids” in his frontal lobe.

CLINICAL INTERVIEW/MENTAL STATUS EXAM:

ABC completed the assessments over one session and he was dressed in a manner that was appropriate for
his age, weather, and situation; however, ABC did indicate that he preferred “jeans, a hoodie, and boots”
and stated that he would wake up “freezing” if he did not wear socks to sleep, no matter the weather.
Throughout testing, he was amicable and presented as an adequately groomed teenager who appeared his
stated age. When asked what his mood was, he answered that he felt “tired and average. The average kid
who doesn’t want to be here, but he has to be here.” His affect appeared to be congruent.

ABC’s attitude toward the evaluation appeared consistent over the session; he also appeared alert and
oriented to the situation. At first, he presented with blunted affect, though his seeming lack of spontaneity
did not hinder his performance. Frequent breaks offered to facilitate testing completion, but ABC did not
take any breaks. He was cooperative at all times, not seeming to need much encouragement from the
examiner though his facial expressions varied only slightly from appearing unresponsive and absent to

This information has been disclosed to you from records of clients whose confidentiality is
protected by State Statute. State regulations limit your right to make further disclosure of this
information without prior written consent of the person to whom it pertains.
 ABC XYZ 5
DOB: XX/XX/XXXX
scarcely interested and detached. When he asked the examiner if he were glad he was “more awake now”
during certain arithmetic tests, the examiner was incredulous since ABC presented in an almost identical
manner to the previous tests and fared nearly the same. Such lack of distinguishing physical detail may
undermine his attempts at social relationships, as others may be confused by his indistinctive gestures. It
appeared that ABC’s vocabulary and reading fluency were average for his age. His rate of speech seemed
normal, and he initiated conversation and developed themes after gentle urging from the examiner.

Overall, his thought processes were logical and coherent, and his thought content was appropriate. ABC
seemed to give up and become frustrated after several difficult items were administered, yet it appeared
that he put at least partial full effort into testing though without much emotional expression. He also
seemed somewhat happy to be given attention. Additionally, ABC did not endorse the presence of any
suicidal or homicidal thoughts, intent, plan, or attempt, and his thought processes appeared within normal
limits with no delusional or hallucinatory content.

VALIDITY STATEMENT:
The following test results are considered an accurate measure and representation of ABC’s current
psychological functioning. The assessment instruments and procedures are deemed valid for this usage
and for this client. No other test results were available for comparison.

TESTING RESULTS:
I. Wechsler Adult Intelligence Scale – Fourth Edition (WAIS-IV): This test is designed to estimate the
level of intellectual functioning of participants ages sixteen and older. Scores are derived by comparing
ABC’s performance to that of a standardized sample of individuals within his age group. Ten is the
average scaled score on the WAIS-IV, and a score between and including eight to 12 is in the average
range. ABC’s scaled scores were as follows:

Verbal Comprehension Scaled Score Perceptual Reasoning Scaled Score

Similarities 8 Block Design 6
Vocabulary 6 Matrix Reasoning 5
Information 5 Visual Puzzles 6

Working Memory Scaled Score Processing Speed Scaled Score

Digit Span 8 Symbol Search 5
Arithmetic 5 Coding 5
**Mean = 10, SD = 3

The average composite score is 100. Average scores range from 90 to 109. Below are ABC’s composite
scores.

Index Standard Percentile 95% Confidence Description

Score Rank Interval
Verbal Comprehension 80 9 75-86 Low Average
Perceptual Reasoning 75 5 70-82 Borderline
Working Memory 80 9 74-88 Low Average
Processing Speed 74 4 68-85 Borderline
Full Scale 72 3 68-77 Borderline
*Mean = 100, SD = 15
This information has been disclosed to you from records of clients whose confidentiality is
protected by State Statute. State regulations limit your right to make further disclosure of this
information without prior written consent of the person to whom it pertains.
 ABC XYZ 6
DOB: XX/XX/XXXX

The FSIQ is the comprehensive score of all cognitive abilities the WAIS-IV assesses and is considered to
be an accurate evaluation of his general intellectual functioning. ABC’s FSIQ of 72 was in the Borderline
range of cognitive skills and knowledge and was above the scores obtained by only 3% of his same-aged
peers. There is a 95% chance that his true FSIQ score lies between 68 and 77.

ABC’s index scores fell within the Borderline and Low Average ranges, but some variation within his
subtest scores was present that alluded to specific strengths and relative weaknesses. ABC’s cognitive
abilities can best be explained by discussing each of the composite scores separately.

The VCI measures verbal abstract reasoning, language development, factual knowledge, and independent
functioning. ABC achieved a standard score of 80, which tied for the highest of all his composite scores
and is in the Low Average range of functioning. His scores on the subtests that comprise the VCI were
limited and may indicate his lack of spontaneity and participation in the classroom and in social
situations. However, within his index of scores, he demonstrated a higher score (Low Average) on a
subtest of abstract reasoning, indicating that he may succeed in solving some problems that are not
straightforward or obvious. He seemed uncertain on a gauge of vocabulary knowledge, and his lowest
score, on a measure of general information that is usually associated with independent functioning,
suggests that he may have a difficult time expressing his wants and needs, leaving him possibly overly
dependent and insufficiently assertive.

On the PRI, which measures nonverbal reasoning abilities and hands-on learning capacities, ABC scored
75, which is in the Borderline range. His scores on the subtests were also varied, suggesting specific
strengths and weaknesses. He demonstrated a relatively higher ability in an area associated with mental
effort, but when requirements involved fine-motor speed, coordination, and visual-spatial reasoning, he
displayed more difficulties. Thus, liabilities in higher-order reasoning when problems require visual-
motor coordination quickness may undermine his confidence in nonverbal learning situations.

The WMI measures the ability to attend to and manipulate simple and auditory information; on this index,
ABC achieved a score of 80, which is also in the Low Average range. His scores on the subtests therein
were again variable, and he did especially poorly when trying to solve word problems requiring mental
manipulation in addition to knowledge of arithmetic. These measures suggest lapses in concentration and
sustained auditory attention that may lead to inattention and poor work habits.

ABC scored a 74, again in the Borderline range, on the PSI, the index that measures his cognitive
processing speed, psychomotor coordination, and visual discrimination skills. His scores on the subtests
that comprise this index were the same, suggesting even but ineffective abilities in this area. He displayed
limited reasoning skills, and his efforts were constricted and hesitant. Thus, he may experience many
frustrations during his everyday written academic work, which would likely limit his output.
ABC appeared to be motivated during testing and presented as at ease and willing, albeit with an
uninvolved affect. His overall abilities are much lower than average for his age, but he did show a relative
strength in his knowledge of societal rules and guidelines, as well as an impressive moral compass, as
evidenced by his refusal to listen to music that espouses values with which he does not agree. These
results are in line with his results on the WIAT-III, reflecting functioning in the Low Average range, with
inconsistency due to motivation but also a lapse in his education.

This information has been disclosed to you from records of clients whose confidentiality is
protected by State Statute. State regulations limit your right to make further disclosure of this
information without prior written consent of the person to whom it pertains.
 ABC XYZ 7
DOB: XX/XX/XXXX
II. Wechsler Individual Achievement Test – Third Edition (WIAT-III): This test is designed to
identify the academic strengths and weaknesses of an individual; inform decisions regarding eligibility for
educational services, educational placement, or diagnoses of a specific learning disability; as well as to
design instructional objectives and plan interventions for a client. For the WIAT-III, the Average range
for Standard Scores is 85-115 with 100 being the average score. ABC’s scores were as follows:

Subtest Standard Score Percentile Descriptive Grade/Age

Rank Classification Equivalent
Reading Comprehension 83 13 Below Average 3.2/8:4
Math Problem Solving 81 10 Below Average 5.7/10:8
Word Reading 96 39 Average 9.2/15:0
Pseudoword Decoding 98 45 Average 10.2/16:0
Numerical Operations 70 2 Below Average/Low 3.7/8:8
Oral Reading Fluency 96 39 Average 9.7/16:0
Math Fluency – Addition 79 8 Below Average 6.2/11:4
Math Fluency – Subtraction 84 14 Below Average 6.1/11:4
Math Fluency – Multiplication 76 5 Below Average 4.5/9:8

ABC’s scores indicated that while his word-reading abilities are like those of a standard 9th or 10th grader,
and his oral-reading fluency demonstrates another relative strength in that it is comparable to a 9th
grader’s functioning, his reading comprehension level is comparable to that of an individual performing at
a 3rd-grade level. This suggests that ABC may be able to decode the words by reading them, but he cannot
seem to internalize their meaning nor get a complete picture of what is transpiring around him.
Furthermore, his various math skills are comparable to those of students in the upper portion of
elementary school. These low scores are consistent with ABC’s stated difficulties in math and further
emphasize his mathematics avoidance though his Below Average performance is more so a result of his
limited cognitive abilities than of a learning disability, as his ability and math achievement scores are
commensurate. Thus, his limited achievement in these important areas of school functioning allude to his
emotional and behavioral difficulties that have interrupted his academic maturation, in addition to his
apparent limitations, and may add to his academic discomfort and undermine his self-assurance.

Composite Standard Score 95% Confidence Percentile Description

Interval Rank
Total Reading 90 85-95 25 Average
Basic Reading 96 92-100 39 Average
Reading Comprehension 86 78-94 18 Average
and Fluency
Mathematics 75 71-79 5 Below Average
Math Fluency 78 71-85 7 Below Average
*Mean =100, SD =15

ABC’s scores on the WIAT-III placed him in the Average to Below Average ranges. His scores on the
Total Reading, Basic Reading, and Reading Comprehension and Fluency composites all fell within the
Average range of scores, while his performance on the Mathematics and Math Fluency composites were
both in the Below Average range. Overall, these results suggest that ABC’s mathematics abilities are
impaired, including his ability to compute mathematical problems quickly and fluently.

This information has been disclosed to you from records of clients whose confidentiality is
protected by State Statute. State regulations limit your right to make further disclosure of this
information without prior written consent of the person to whom it pertains.
 ABC XYZ 8
DOB: XX/XX/XXXX
III. Vocational Measures: Career Ability Placement Survey (CAPS) and Career Occupational
Preference System (COPS): ABC was asked to complete the tests in the Career Ability Placement
Survey (CAPS) and Career Occupational Preference System (COPS; as elf-report interest inventory
designed to work concurrently with the CAPS) to determine the occupational areas in which he might
have the most career aptitude, where he might encounter the most job satisfaction, or where he might need
the most special training. To this end, he was asked to engage in various tasks that echoed those
conducted in the WIAT-III and WISC-IV but that were more fine-tuned towards skills need for various
career fields. Additionally, although the CAPS generates percentile rankings and stanine scores, and the
COPS’s Likert-scale responses generate percentile scores, the data of the former is best understood in
terms of propensity towards one of 14 Career Clusters, and of the latter, a protocol that corroborates the
former’s findings.

The CAPS is a series of tests that assists with ascertaining an individual’s strengths, weaknesses, and
potential as it relates to career development. Specifically, the results help to predict an individual’s
likelihood of success in multiple professions and assist in vocational planning (e.g., selection of school
courses and training programs). The COPS inventory is designed to help an individual plan a career.
Scores help to determine an individual’s relative interests in activities performed in many different
occupations.

ABC’s scores on the CAPS spanned a range from Low to Below Average to A Little Below Average. He
displayed relative weaknesses and clinically significant limitations through his Low scores on tasks
involving Spatial Relations, which pinpoints how well one can visualize three dimensional objects;
Numerical Ability, how well one reasons with numbers and works with quantitative materials and ideas;
and Perceptual Speed and Accuracy, which identifies how well one perceives small detail rapidly and
accurately. Additionally, ABC performed in the Below Average range on tasks involving Mechanical
Reasoning (i.e., understanding mechanical principles and the laws of physics), Verbal Reasoning (i.e.,
how well one can reason with words and one’s understanding and use of concepts expressed in words),
Language Use (i.e., the ability to recognize grammar, punctuation, and capitalization rules), and Manual
Speed and Dexterity (i.e., how well one can make rapid and accurate movements with one’s hands).
Finally, he demonstrated his highest score, a relative strength, with his performance in A Little Below
Average on assessments of Word Knowledge, the ability to understand the meaning and precise use of
words.

These results indicated that ABC demonstrates abilities that coincide best with the following job domains:
Outdoor (e.g., auto mechanic, construction trades), Skilled Service (e.g., gaming surveillance officer,
occupational safety and health), Skilled Technology (e.g., electrician, computer technology), and
Consumer Economics (e.g., manufacturing, crafts). These results are consistent with ABC’s disclosed
interest in computer programming and electrical work; thus, it may be likely that his abilities would allow
him to find success in these fields. Please see the discussion section for further information regarding
these results.
Individuals who achieved the same scores as those found on ABC’s CAPS protocol, his Career Profile,
often succeed and find satisfaction in the following four of the aforementioned clusters, in descending
order: Outdoor, Skilled Service, Skilled Technology, and Consumer Economics. This Career Profile
indicated success in only these areas due to ABC’s obtaining stanine scores below average on all eight
domains in which he was assessed. These clusters can best be explained by discussing each separately.
However, CAPS data, as mentioned earlier, must be considered relative to the COPS; despite ABC’s
desire to engage in certain professions post-high school, his ability and/or current training may preclude

This information has been disclosed to you from records of clients whose confidentiality is
protected by State Statute. State regulations limit your right to make further disclosure of this
information without prior written consent of the person to whom it pertains.
 ABC XYZ 9
DOB: XX/XX/XXXX
his success, or at least frustrate him to a point that would prevent his succeeding, therein. Therefore, only
the intersecting career cluster of the CAPS and COPS will be elucidated below.

On the COPS, ABC indicated that engaging in skilled technology would bring him the most enjoyment
(i.e., 80th percentile); the next-highest elevation in self-proclaimed job satisfaction was over fifty
percentile points lower, indicating that ABC is intensely focused on becoming a professional in this field
and an expression of less-than-passionate interest in any of the other areas assessed. As such,
understanding what is required of individuals in this field is imperative. Those with Skilled-Technology
(i.e., occupations involving working with one’s hands in a skilled trade concerned with construction,
manufacture, installation, or repair of products) profiles often conduct their professional activities with
their hands. They tend to best be served in realms involving a skilled trade, construction and
manufacturing, installation and repair, and/or working with electronics and mechanics. Should ABC wish
to pursue higher education to this end, he and his guidance counselor or potential college admissions
representative should look towards majors in civil-construction or electrical work. Finally, some skills an
individual with this profile might need to be successful are an ability to use machines artfully and to pay
strict attention to guidelines and standards.

Based on these results, it seems that ABC’s interest and ability in the Skilled Technology domain are
consistent, indicating a likelihood that he could achieve both success and fulfillment in careers within this
field. Although results indicated a significant skill in the Outdoor professions, ABC is best suited for his
reported preference in electrical work, computer programming, or other careers in the Skilled
Technology industry. Please see the discussion section for further interpretive information regarding
these scores.

Further speculation as to which other fields would bring any ABC job satisfaction seems an exercise in
futility, as evidenced by only 12 endorsements on the COPS of “like very much,” one of “like
moderately,” and the rest (i.e., 113) “dislike very much.” Additionally, although the findings of the
WAIS-IV, WIAT-III, and the Purdue Pegboard Dexterity Test may corroborate CAPS data, without
desire on the part of the examinee, no amount of proof would render sufficient.

V. Purdue Pegboard: This is a test of dexterity and it is designed to aid in the selection of employees for
industrial positions such as assembly, packing, operation of certain machines, and other manual jobs.
ABC identified as right-hand dominant; his scores were compared with those of adult male OVR
candidates (age 35 and under).

Test (3 trials each) Average Number of Standard Score Description

Pins
Right Hand** 13.33 99 Average
Left Hand 14.67 105 Average
Both Hands 10.00 97 Average
Right, Left, Both 38.00 101 Average
Assembly 43.33 121 Superior
*Mean = 100, SD = 15
**Indicates dominant hand

ABC performed in the Average range on 80% of the Pegboard tasks, scoring in the Superior descriptive
level on the Assembly stage; however, this last score may have been incorrectly evaluated; thus, the
This information has been disclosed to you from records of clients whose confidentiality is
protected by State Statute. State regulations limit your right to make further disclosure of this
information without prior written consent of the person to whom it pertains.
 ABC XYZ 10
DOB: XX/XX/XXXX
results of the Assembly task should be interpreted with some caution. While ABC learned how to manage
the single- and double-handed assignments within the time allotted for reading the directions and practice,
he seemed to have difficulty navigating the concurrent way each step of the Assembly stage was to be
completed. For example, the instructions clearly state that as the first item is being dropped with one
hand, the other hand should be picking up the next layer, and so on, but ABC waited until each item was
securely fastened to begin even gathering the next. This may indicate an inflexibility regarding following
directions or an inability to focus his movements bimanually.

VI. Projective Drawings: The House-Tree-Person test is a projective test (i.e., indicating aspects of
personality) in which ABC was asked to produce three drawings: a house, a tree, and a person. He then
described, defined, and interpreted her drawings. Results are also highly sensitive to the presence of
psychopathology. ABC’s results were as follows:

ABC approached this assessment in a hesitant manner and commented on his lack of artistic talent. For
his house rendition, he related that it was a two-story brick house, which he identified as expensive. He
stated that if he were to live in the house, he would choose to be alone in it, as “people are annoying.” The
tree ABC drew was quite large, and he described it as a strong oak. He noted that it appeared to be a man
due to how high it was standing. For the person, ABC initially drew it as a stick figure, and he was
hesitant to amend it when prompted, saying that “This is all you’re going to get from [him].” His drawing
depicting a person was said to be a 25-year-old man, who was noted to be “a random person walking
down the street.” He reported that this man was smiling because he had everything he wanted. ABC also
remarked that the person he drew seemed “chill.”

From a thematic standpoint, ABC’s drawings were suggestive of insecurity, inadequacy, withdrawal,
helplessness, and a poor understanding of reality. Such findings may be indicative of an underlying
perception of and sensitivity to environmental pressures across settings. ABC may feel irritation toward
his home life, including feelings of hostility and frustration, which may reflect unresolved discontent with
the separation of his family structure. ABC’s social ambivalence appears to be generalized to other
relationships, as his drawings seemed to convey themes of aggression but also a need for compensation. It
is possible that he may feel compelled to guard himself from others, as his sense of safety may have been
negatively affected by the absence of his father, abuse from caregivers, and the tenuous nature of his
home life. This finding is also consistent with ABC’s reports of being victimized by peers through verbal
and physical aggression. ABC’s potential fears of being harmed by others and/or further loss may lead
him to withdraw and isolate himself. This tendency appears to be juxtaposed with an inclination for
dependence and poor self-worth. Through this failure to launch, ABC may satisfy an urge for frequent
reassurance that he will not be abandoned by family members. Moreover, his drawings suggest personal
insecurities and an overall sense of inadequacy, which may be exacerbated by feelings of helplessness and
a loss of autonomy. Although ABC appears to be very concrete and goal oriented, he may possess an
underlying fear that his strivings are unrealistic. Please see the discussion section below for further
interpretive information regarding these results.

An examination of ABC’s simplistic projective drawings revealed an unsophisticated and ungrounded

individual who tends to view the world in concrete terms through a lens of personal inadequacy. He
appears to perceive a moderate degree of environmental stress but has no emotional protection, as his
defense structures are inflexible and rigid yet brittle. ABC is guarded and does not wish to be vulnerable
with others. He uses his thoughts more than his feelings during decision-making but often acts without

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protected by State Statute. State regulations limit your right to make further disclosure of this
information without prior written consent of the person to whom it pertains.
 ABC XYZ 11
DOB: XX/XX/XXXX
regard to consequences, executing poor judgment due to his frequent bouts of uncertainty. The presence
of several of these character traits is further supported by his sentence completions.

VII. Projective Assessment: The Sentence Completion Series: Work Form was used for ABC’s
projective assessment. The Sentence Completion Series assessed his perceptions related to family. The
assessment required him to finish incomplete sentences through written expression. The present themes
were as follows:

For the Sentence Completion Series: Work, ABC was asked to write the endings for 50 incomplete
sentences about his experiences regarding work, as honestly and openly as possible, with the first thing
that came into his head. While every item of the measure may not apply to each individual assessed, the
task suggested working in order but then returning to make up any that may have been skipped. Despite
these instructions, ABC still did not finish every item with a complete sentence, nor did he address every
idea with a complete thought.

ABC’s sentences confirmed his earlier statements in the clinical interview that his handwriting was
underdeveloped, difficult to decipher, and accomplished hurriedly. Furthermore, his responses indicate
the presence of an immature psyche that has not reached its developmental milestones and is not headed
towards that trajectory, as evidenced by responses such as, while at my job “I’m working,” to know I’ve
done good work I’ve done “a good job,” and “As a worker I do my work.” ABC’s completed sentences
further reveal a torn individual who has contradictory beliefs and who cannot seem to decide what it is
exactly that he wants (e.g., my best work is done “solo” but doing a job by myself “is boring,” working on
a team “good,” and owning my own business “bad idea”) and puts too much emphasis on seemingly
unimportant concepts (e.g., If I had no need to work “I would be a nobody” and my work ethic “is
average,” but my future career plan is “high school college” but also my work future includes
“manager.”). Finally, he appears to have gotten caught up in the belief of a career in computer
programming or electrical work but may not completely believe that himself, or at least does not wish to
exert himself to achieve this goal. This was indicated by his stating he would have no options to change
occupations from his best job of “programming” but also that his “greatest ambition is video games.”

DISCUSSION:
ABC XYZ is a 17-year-old, White male currently residing in the community of COUNTY. He was
referred for psychological testing to assess his current emotional and cognitive functioning, with an
emphasis on issues related to career placement and aptitude assessment. There were also questions related
to treatment direction.

ABC was reported to have met all his developmental milestones on time and lives with his biological
mother and her boyfriend, as well as several other relatives, immediate and otherwise, in a house that is
reported to be too small for everyone. He will be attending HIGH SCHOOL as a senior after the summer
finishes.

ABC arrived on time for his testing session, was dressed appropriately for the weather though somewhat
warmly, and appeared his stated age of 17. ABC seemed alert and aware of what was happening though,
at several instances, he marveled bemusedly that he was incredulous as to how anyone would enjoy
conducting these assessments.

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protected by State Statute. State regulations limit your right to make further disclosure of this
information without prior written consent of the person to whom it pertains.
 ABC XYZ 12
DOB: XX/XX/XXXX
Throughout ABC’s testing, he appeared to be motivated and presented willing to engage in conversation
but was noticeably bored and tired during the actual testing. His overall abilities appear much lower than
average for his age, but he does show relative strengths in his perceptual reasoning on a concrete level and
ability to attend to auditory information. However, he demonstrates substantial deficits in areas associated
with abstract reasoning, fine motor coordination, and copying speed. He also showed a substantial
weakness when confronted by math-related problems that is commensurate with his ability; however, his
reading achievement scores were higher than expected, given his IQ scores. These results were in line
with his previous IEP, with inconsistency due to a lapse in his education and emotional problems
interfering with attention to detail and lack of self-confidence. However, as stated earlier, these deficits
are more than likely related to his cognitive functioning level than to a learning disorder.

The results of ABC’s vocational assessments indicate that he may be best served working with his hands
in realms involving a skilled trade, construction and manufacturing, installation and repair, and/or
working with electronics and mechanics.

It appears that ABC is currently experiencing some emotional stress, which interferes in decision-making
and judgment. The assessment further indicated that he suffers from low self-esteem and frequently feels
isolated though his lack of sophistication prevents him from always feeling overwhelmed. His ability to
maintain concentration is impaired, and his apparent lack of motivation only increases his academic
difficulties, which further impacts his initiative and confidence. ABC’s responses on self-report measures
reflect significant symptoms of anger and low self-worth. Overall, his profile suggests a vulnerable youth
with few emotional defenses to cope with daily stressors and challenges.

ABC reported having been diagnosed with Tourette’s Disorder, ADHD, and ODD in the past. He also
stated that he smokes anywhere from one to two cigarettes daily but can consume up to 10 if he is
specifically under stress, hence the Tobacco Use Disorder, Mild diagnosis. Additionally, ABC has
endorsed having low energy and poor concentration, as well as getting irritated easily and having
significant impairment in educational functioning, for the past several years, resulting in the diagnosis of
Persistent Depressive Disorder. ABC further indicated the possibility of being the victim of physical
abuse by his mother’s partner; thus, the Physical/Sexual Abuse/Neglect of Child (victim) 'v code' was
attached. Moreover, ABC’s low intellect, as indicated by the Borderline Intellectual Functioning
diagnosis, will create a substantial weakness in everyday social performance. The Parent-Child Relational
Problem V code represents the paternal abandonment and estrangement. Finally, ABC stated he freely
gets frustrated and angry and isolates himself, stating that he does not enjoy other people’s company, the
effect of which could be the provisional diagnosis of an Unspecified Anxiety Disorder.

DSM-5 DIAGNOSTIC IMPRESSIONS:

305.1 (Z72.0) Tobacco Use Disorder, Mild
307.23 (F95.2) Tourette’s Disorder, provisional (by history)
314.01 (F90.9) Unspecified Attention-Deficit/Hyperactivity Disorder, provisional (by history)
313.81 (F91.3) Oppositional Defiant Disorder, provisional (by history)
300.4 (F34.1) Persistent Depressive Disorder, Moderate, Early onset, in partial remission
300.0 (F41.9) Unspecified Anxiety Disorder (provisional)
V15.41 Physical/Sexual Abuse/Neglect of Child (victim)
V61.20 Parent-Child Relational Problem
V62.89 Borderline Intellectual Functioning

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protected by State Statute. State regulations limit your right to make further disclosure of this
information without prior written consent of the person to whom it pertains.
 ABC XYZ 13
DOB: XX/XX/XXXX
CLINICAL IMPRESSIONS:
Strengths:
ABC:
 presented information in an open and honest manner
 appeared goal-directed and future-focused.
 plans to pursue a career as a computer programmer or high-voltage electrician.
 reportedly enjoys playing video games.

Concerns and Functional Limitations:

ABC:
 demonstrated difficulties with processing speed, math fluency, and fine-motor skills.
 experiences ongoing familial conflict.
 has limited social supports beyond his mother and the family with whom he lives.
 has a perceived historical experience of being bullied.

Recommendations:
Education:

1. Relative to ABC’s Individualized Education Program (IEP), he should enroll in a highly

structured, small-class-size setting to provide him with the necessary assistance to stay on task to
reduce his impulsivity and aggressive behavior.

a. ABC will function most effectively in environments that are well structured and free of
ambiguity. Thus, clear explanations about expectations of everyday tasks are crucial for his
completion of assignments. ABC should be given simple, concrete, and specific
instructions to understand the rules and directions better.

b. Oral praise should be provided when ABC completes tasks satisfactorily to help improve
his self-esteem within the classroom. When giving constructive criticism, it should be done
in private, followed by encouragement for his efforts. ABC responded quite well to the
consistent positive reinforcement he received during the testing sessions. Verbal praise
may serve not only to reinforce his efforts, but it may also be effective in building self-
esteem and confidence.

2. ABC’s IEP should be updated to include the findings from this report, including the diagnostic
impressions. Further accommodations should be included that would be crucial in assisting him to
reach his potential. Without such accommodations, ABC would be at an unfair disadvantage
compared to his peers.

3. New materials should be reviewed frequently to help ensure that he is grasping the underlying
concepts.

4. All basic academic skills need to be reviewed and enhanced. Reading and math need to be
reinforced each day.

a. His reading skills appear to be a relative strength, and success in reading can strengthen his
self-esteem and may lead to many areas of academic success.

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protected by State Statute. State regulations limit your right to make further disclosure of this
information without prior written consent of the person to whom it pertains.
 ABC XYZ 14
DOB: XX/XX/XXXX
b. On tests of mathematical ability, ABC would benefit from having paper available so that
he can work out problems in writing. A calculator may also be instrumental in helping him
work through more complex problems without added frustrations.

5. ABC’s problem-solving style is generally haphazard, and he is likely to give up quickly when
presented with challenging problems. It is important that he be coached to edit his work to reduce
inattentive errors. Encouraging him to read his written work aloud or talk through math equations
and written assignments may alert him to careless errors.

6. ABC needs encouragement to continue thinking through problems when he begins to struggle with
a question on an assignment.

a. Tangible rewards should be provided for demonstrating sustained concentration and for
completed work.

i. A token economy may be implemented where ABC can “purchase” items with
points he has earned by attending to tasks for a predetermined length of time.

b. Shorter tasks may need to be assigned and then the length of time needed to complete them
to be increased gradually.

Occupational:

7. ABC would benefit from occupational therapy services that focus on his coordination problems,
written ineffectiveness, perceptual-motor integration, and efficiency. An occupational therapist
should be consulted for this type of evaluation and will plan additional interventions accordingly.

8. ABC should continue repairing small electronic devices by taking them apart and putting them
back together, as this will help him gain practice and confidence in the career areas he noted
preference.

9. Should further exploration of the potential professions in which ABC demonstrated aptitude be
warranted, guidance counselors or college admissions representatives should direct interested
parties toward the following clusters: Nature, Skilled Service, and Consumer Economics.

10. ABC should find a part-time job or apprenticeship at a garage or construction site or with an
electrician, as on-the-job training may be one of the best ways he will become a consumer of the
necessary educational materials.

a. OVR can facilitate this by organizing opportunities for ABC to have a job shadow worker
with one of their employer partners.

Therapy:

11. Individual therapy targeting ABC’s impulsivity, hostility, and depressive affect is recommended to
help him learn alternative ways to cope with daily frustrations.

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protected by State Statute. State regulations limit your right to make further disclosure of this
information without prior written consent of the person to whom it pertains.
 ABC XYZ 15
DOB: XX/XX/XXXX
a. He has difficulties identifying and expressing his emotions appropriately and often
becomes frustrated and has acted out aggressively. Cognitive Behavioral Therapy
techniques would be helpful to identify his thoughts and emotions that lead to his
frustrations and to help reframe his thought processes and respond in a more positive and
appropriate manner.

b. This type of therapy would help him expand alternative reasons for past occurrences and to
begin more realistic and optimistic future thinking.

c. Treatment goals should include reacting more pro-socially and decreasing hostile
behaviors.

12. Therapy to support ABC’s strengths is recommended to help him develop an improved self-image.

a. One intervention could be having ABC create a list that highlights his strengths and
positive qualities and a discussion about how he could utilize those qualities in everyday
interactions.

13. ABC’s therapy should also center on the abandonment by his father, as this certainly plays a role
in how he interacts with others.

a. The therapist should focus on how this has aided in the development of ABC’s avoidant
personality style and how that can prevent positive interactions and results in negative
consequences.

14. Suicidal ideation may need to be monitored given his level of depression.

15. ABC has a history of self-injurious behavior and has previously cut when under stress. Therefore,
he may require additional support during particularly stressful events.

16. ABC should collaborate with his therapist on learning coping skills and anger management
techniques such as diaphragmatic breathing, meditation, mindfulness, and/or guided imagery that
may help him handle intense emotions better.

a. Reinforcement of alternative coping mechanisms to process stressors are essential to

decrease his impulsive and aggressive behaviors.

b. Therapy should focus on challenging ABC’s reliance on avoidance and encouraging him to
express his emotions and negative feelings in a healthy way. Therapy can help him identify
the links between his thoughts, feelings, and behaviors.

a. ABC’s therapist should determine to what extent he is feeling anxious, if at all, and
rule out the possibility of an anxiety disorder.

It was a pleasure working with ABC. Please contact me if any questions or concerns arise.
________________________ ________________________
SUPERVISOR, Psy.D., L.C.S.W. Joshua Gonsher, M.A., M.S. Ed.
Supervising Licensed Psychologist Psychology Intern
LICENSE #
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protected by State Statute. State regulations limit your right to make further disclosure of this
information without prior written consent of the person to whom it pertains.
 ABC XYZ 16
DOB: XX/XX/XXXX
Appendix

Resources for Recommendation One through Six:

 Improving Math Fluency - https://mathfactspro.com/math-fact-fluency-game/

 Recommended Electronic Resources, Programs, and Websites
o Lumosity - https://www.lumosity.com/landing_pages/1023
o Cognifit - https://www.cognifit.com/
o BrainTrainer - https://brain-trainer.com/
o Fitbrains - http://www.fitbrains.com/

Resources for Recommendation Seven:

 Occupational Therapy to help with fine-motor and dexterity skills

o “Handwriting Without Tears” - https://www.lwtears.com/
o “Strategies for Dealing with Dysgraphia” - http://www.ldonline.org/article/5890

Resources for Recommendation Eight:

 STEM kits available for purchase online or in retail stores

o HomeScienceTools.com
o MakeBlock.com

Resources for Recommendation Nine:

 The Nature Conservancy - www.nature.org

 Tradesmen International - www.tradesmeninternational.com
 My Plan - https://www.myplan.com/

Resources for Recommendation 10:

 Apprenticeships:
o Indeed.com
o ZipRecruiter.com
o National Electrical Contractors Association (NECA)

Resources for Recommendation 11:

o Agencies that do psychological testing

o PSYCHOLOGIST

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protected by State Statute. State regulations limit your right to make further disclosure of this
information without prior written consent of the person to whom it pertains.