CONFIDENTIAL PSYCHOLOGICAL EVALUATION

(This must always be on top)

I. IDENTIFYING DATA

Age (date of birth):

Sex: Ethnicity:
Date of Report:
Name of Examiner:
Referred by:

Write here the basic information of your client in paragraph form. Other information
may be placed in the history.

II. PRESENTING PROBLEM/REFERRAL QUESTION

Write here the description of the concern/problem raised by your client.

III. MENTAL STATUS EXAMINATION

Mental Status Examination and Behavioral Observations: Affect was ______________. Mood
was ______________. The thought process was logical, sequential, relevant, and coherent.
Thought content was reality-based and normal. Short-term memory functioning was
______________. Long-term memory functioning was normal and intact, as evidenced by
______________’s ability to provide age-appropriate historical information.
______________ was oriented to time, place, and person. The activity level was normal.
Social skills were normal including effective eye contact and reciprocity. Estimated
intellectual function based on verbal skills and reasoning abilities is average. Psychotic
symptoms were not evident. There was no evidence of suicidal thoughts, intentions, or plans.
There was no evidence of self-mutilation or self-harm.

IV. BACKGROUND INFORMATION (Relevant History)

Psychiatric/Medical/Psychological:
The referring clinician completed a Behavioral Health Evaluation (i.e., 90801) in or about
______________. No Behavioral Health Evaluation (i.e., 90801) has been done within the
past year. Psychiatric history includes outpatient treatment by ______________. Family
psychiatric history is negative positive for ADHD, Bipolar Disorder, Depressive Disorder,
Schizophrenia, Dementia, and Learning Disorder. Medical functioning is unremarkable
remarkable for ______________ is not taking any current medications. Current medications
include ______________. There is a negative history of severe head injuries, seizure disorder,
and major surgeries. Vision is normal. H earing is normal. ______________ has been in
psychosocial therapy for ______________. Previous neuropsychological testing has not been
done.
 Developmental: There were no pre-, peri-, or post-natal complications reported. Gestation
was full-term. Birth weight was ______________ pounds ______________ ounces. Birth
length was ______________ inches. Developmental milestones were reported as falling
within the normal range.

Family: ______________ lives with ______________.

Interpersonal: Interpersonal relationships were described as satisfactory in both quality and

quantity. Social skills were described as ineffectual with deficits in friendships of adequate
intimacy.

Educational: ______________is in grade ______________. Academic performance has

typically been ______________. Behavioral grades have typically been ______________.
There has been no grade retention. ______________ was retained in grade ______________,
is receiving general special education instruction, has a continuing IEP, and is classified as
______________.

Vocational: None.

Substance Abuse: Unremarkable.

V. ASSESSMENT PROCEDURES
Write here the names of the tests and the date the tests are taken.

Name of the Tests Date Taken

VI. TESTS RESULTS & INTEPRETATION

Write here the results & interpretation from each of the tests you have taken via

PsychSurveys. Please make sure to write the implications of the results.

VII. CASE DISCUSSION AND FORMULATION

Write here the integration of your analysis.

Discuss the following domains per paragraph:

A. Intellectual/Cognitive Functioning
B. Neuropsychological Functioning
C. Personality Functioning
D. Socioemotional Functioning
E. Spiritual Functioning

VIII. CLINICAL IMPRESSION

 Write here your working impression. Use DSM 5 as your reference. Include one

theory of personality to support your analysis and conclusion about the client’s

case.

IX. RECOMMENDATIONS

Write here feasible recommendations that may help your client. Indicate

recommendations that may help improve the client’s functioning.

Evaluated by:

Signature above printed name of the

assessor & the date signed

 APPENDIX

Include here the original signed informed consent, the notes from the interview,

the notes from the observations conducted, and the materials used for the

evaluation.

Other Instructions:

Always write using third person (e g., The assessor, the client) & NOT first person (e g.,
I saw, I observed)

Double space, Times New Roman Font, size 12

Put CONFIDENTIAL as water mark of the document

Minimize unnecessary words, write concisely but clearly.

Read and check your own work before submitting