PSYCHOLOGICAL ASSESSMENT REPORT

Name: Date of Assessment:

Date of Birth: Age at Assessment:

Reason for Referral:

Tests Administered: Date Administered:

Additional Material Considered for this Report: Date:

Intake Interview
Behavioral Observations

RELEVANT BACKGROUND INFORMATION

Personal, Family, and Social Histories

TEST RESULTS

Manchester Personality Questionnaire

BarOn Emotional Quotient Inventory:Short

Differential Aptitude Test

DIAGNOSTIC IMPRESSION

Cognitive Functioning

Behavioral Functioning

Emotional/Psychological Functioning

Interpersonal Functioning

Intrapersonal Functioning

Summary

RECOMMENDATIONS

Prepared by: Reviewed by:

(Your Name & Signature) (Name of Your Instructor)
Name of Examiner Supervisor