Assessment Report

Demographic Information
Name: Jane Doe DOB: 12-12-2000
Address: 123 Spruce, Mansfield PA Age: 20
Gender: Female
Phone: 570-123-4567 Ethnicity: White (non-Hispanic)
Email: janedoe12@mansfield.edu Date of Interview: 4/12/20
Name of Interviewer: Rebeca Pizzo

Presenting Problem or Reason for Referral

Jane Doe is a 20-year-old white female of a height of 5’7 and a medium build. She
was self-referred to the university’s Counseling Center for assessment and
possible counseling related to high levels of stress, panic attacks, and inability to
sleep regularly and without nightmares. Jane Doe reported that she has been
finding it increasingly difficult to leave her residence hall room in order to attend
classes after explaining that she has no energy to do anything anymore from walk
to class, talk to friends, even eating food. She has been having difficulty sleeping
and has vivid nightmares that keep her up at night. She stated she is in danger of
failing if she cannot gain control over her energy levels and motivation. Jane Doe
was very open to discussing her situation and she stated she is willing to do
whatever it takes to get her grades up and continue her education. An assessment
was conducted to determine differential diagnosis and best course of treatment.
Family Background
Jane Doe was raised in Mansfield, PA. She is the youngest of two and has older
brother. She reported that her parents were always overly protective of her being
that she was the only girl in the family, but in the years not been very active in her
life. Her mother passed away a year back. Jane Doe describes her relationship
with her father as healthy but not very affectionate. She said it is rare for her
father to display physical affection, and she finds it difficult to express her feelings
to him when she is feeling down or lonely. er brother never had problems
growing up and easily separated from home when it was time to go to college
because he is so much older than her. She does not have much contact with her
brother now that their mother has passed away, and the father is not very
welcoming to him at home, so he does not come around, even for holidays.
Jane Doe reported that she had been reluctant to go away to college because she
thought it might be too challenging for her to leave her father on his own. Since
her mother passed away, she has been taking over her chores around the house
and cooking for her father.
Before her mother passed during the summer before college, Jane Doe and she
would always talk about her becoming a doctor and helping people like her
mother get healthier. However, once college started, she was soon overwhelmed
with the work a biology student has. She does not like the major and wants to
switch out, but she also does not want to let her mother down. Jane Doe took on
a minor as a psych student and completely loves it, however like stated before
she does not want to let her mother down by not becoming a doctor. She was
able to maintain a C average and that she said that she made few friends this past
semester, but typically felt alone and that nobody at college or home cares about
her.
Significant Medical/Counseling History
Jane Doe has never had any type of medical or counseling history. She said she
had asked to go to therapy after her mother died, but her father could not be
bothered to help her, so she gave up asking. Jane Doe then heard of the free
college counseling when she applied. She has explained how she liked how it is
anonymous and nobody knows. She was afraid at first that her father would find
out and that he would shame her. So far, she has stated that she wants to come
every week, even with her lack of energy.
Substance Use and Abuse
Jane Doe stated she has consumed a lot of alcohol in her first semester, currently
she is in her second. She said at the time she had a lot of friends and they would
party whenever they could. However, with the time she spent away from studying
and the course load she has from her major she had to stop going out because
her grades were dropping. With not going out as often as her friends, they still
remained in contact but were not caring towards her and stopped inviting her
places.
Educational and Vocational History
Jane Doe attended public school through 12th grade. She said she did not have any
attendance problems nor problems making friends all throughout high school. She
said school was easy and enjoyable. Her favorite subjects that she took in high
school were English and AP Writing.
Jane Doe is a second semester biology major with a psychology minor. Like stated
before she chose biology to become a doctor, and psychology because she is
interested in the subject. She said she is having trouble in classes that are new
subjects for her like anatomy and physiology, molecular bio, and organic
chemistry. She had no difficulty with her English and writing classes. Overall, she
said that she is behind because her first semester she did not study and retain any
information, and that everything is connected, and she is lost. She stated that she
does not have a love or passion for the major and that it is really bringing her
down mentally and educationally.
Other Pertinent Information
Jane Doe reported that she has lost weight this semester due to not having
enough energy to walk to the dining hall.
Jane Doe reported that she struggles to stay focused in class due to several
reasons every day: not understanding the material, thinking about her mother,
and worrying about her father.
Jane Doe reported that she experiences panic attacks when she thinks too in
depth about her mother and how her father is doing. In these panic attacks she
describes them as difficulty breathing, overheating, shaking, and feeling like she is
going to pass out.

Mental Status
Jane Doe arrived on time for her appointment and was dressed in sweatpants and
a sweatshirt. Hygiene and grooming were moderate, you can tell she has not
showered in the past 48 hours. She has bags under her eyes so one could tell she
has not gotten into a proper sleep routine. She had very seldom eye contact, was
soft spoken, and apologized often for no reason.
Her affect was anxious, muted, slumped which consistent with her reported
mood. Her verbal expression suggested at least average intelligence. No
difficulties with memory, comprehension, or judgment were noted. She was
oriented to person, place, and time.
She reported her main concerns were general feelings of anxiety, depression, ne
energy/ motivation. She wanted to get better grades and to get ahold of her
future.
Tests Results
The following tests were administered: Wide Range Achievement Test-4 (WRAT-
4), Shipley Institute for Living Scales, IQ tests online at IQ.com and the Great
British Intelligence Test, WAIS Digit Span Subtest, Stress Test, Procrastination Test,
Interpersonal Behavioral Scale (IBI), State-Trait Anxiety Inventory, Manifest
Anxiety Test, Beck Depression Inventory, Myers-Briggs Personality Profile, IPIP-
NEO Big 5 Test, and Incomplete Sentence Blanks.

Educational assessment using the WRAT-4 indicated average academic abilities

based on age group expectations.
Her math standard score of 97 and spelling score of 46 were in the 40 nd (average)
and 15th percentile (low average). There were no indications of learning disorders
although she is relatively weak at spelling.
Measures of intelligence included the Shipley Institute of Living test showed a
Verbal score that converted to a dIQ of 100 and Reasoning dIQ of 126. Her Overall
dIQ was 78. These scores all fall in the average to lower range.
Jane Doe’s score on the Einstein range test was 180 which is above average in
range. Jane Doe said she did not put a lot of effort into this test and eventually
ended up guessing on a lot of the questions because she was not into it.
Jane Doe on the Great British IQ test scored in the upper 50% on Verbal Working
Memory, Verbal Reasoning, and Verbal Comprehension, Spatial Intelligence,
Spatial Working Memory, and Mental Rotation.
Overall, the academic and cognitive tests do not indicate any significant leaning
difficulties that might be impairing her school performance.
On the Stress Test Jane Doe scored a 67 out of 100. She is on the higher side of
the stress chart. These factors are due to schoolwork and home life.
Jane Doe’s score on the Procrastination Test was a 49 out of 100. She is below
average for this score. When asked why she stated that she has been trying to get
better at doing schoolwork. She explained that she is organized however she just
lacks the motivation to get it done.
Jane Doe scored high for Neuroticism on the Big 5 Personality Test. Meaning she
is easily upset, and more sensitive than the average person. That test also
described her as being introverted, quiet, sympathetic, and down to earth.
The Myers-Briggs Test identified her as an ISFP. This means that she is
introverted, has high sensory, strong feelings, and does well with perceiving
others.
Jane Doe’s incomplete sentence blank responses matched her personality, and
her past. Some sentences that she stated that raised my eyebrow were, “My
greatest fear is losing my father and not knowing what to do after “, “My mind
feels like it is too much for me sometimes”, “My nerves feel shot”, “I am very
passionate about psychology but not the schooling part”,” The happiest time is
‘when I go home and see my beagle’…. Etc. These raise concern because she is in
constant worry, especially about things she cannot control, and it is taking a toll
on her body. Along with that, her only positive thing she looks forward to is going
to see her dog.
Diagnostic Impressions
Generalized Anxiety Disorder
Depression
Summary and Conclusions
Jane Doe is a second semester freshmen. Her first semester of college she was
not in the right place and did not make the best choices to help her during her
second semester. During the current semester she is finding the work more
challenging and that it raises her anxiety level to which she then overthinks and
then finds herself with no motivation to do anything.
Testing showed that Jane Doe is quite intellectual and has no evidence of learning
disorders, so she is capable of college level work. However, she does not have
any desire to keep up with her current major. She is working through changing it
to make her future more positive for her and working to help her cope with not
going down the pathway her mother wanted her to.
Jane Doe is reporting a high degree of anxiety and stress and low energy levels.
Her confidence is low, but that is something to be worked on. She will excel in
college and needs a schedule to keep her busy and energized.
Recommendations
1. Individual counseling to build coping strategies for managing anxiety and
depression
2. Stress management training
3. Change in major
4. Family counseling