Letterhead/logo of facility/center

PSYCHOLOGICAL ASSESSMENT REPORT

Name
Age/Sex
Birthday
Educational Level
Date of Examination
Purpose of Testing Assessment and Intervention or Court Case

Assessment Measures

IQ test
Bender Visual-Motor Gestalt Test
Draw a Person Test/KFDT/HTPT
Trauma Inventory for Children/Adult
Behavioral Observation
Clinical Interview with (mother/informant)

Case History
( emphasize: significant traumatic event/ signs and symptoms of trauma/effects of trauma on
cognitive like academic performance; emotional; social and occupational functioning)

Behavioral Observation
(speech/reality testing/rapport/attitude toward testing and Psychologist)
Page 2. Name of the Client/Patient )

Clinical Findings and Impression

Test Findings
integrated test interpretation validated from the relevant case history and behavior observation;
1st paragraph - IQ interpretation
2nd paragraph - emotional
3rd paragraph - social/occupational

Impression: If the criteria are met and trauma symptoms are strongly evident then state the disorder.
If some symptoms are evident then state Trauma symptoms are evident/manifested.
If no trauma symptoms then Trauma symptoms are not evident/manifested.
Recommendation: if for intervention, if there is a disorder then present type of intervention to be
recommended

Name of Psychologist over Signature

Clinical Psychologist
Lic. No.