Report Template 10f2l

Report Template PSYCHOLOGICAL EVALUATION (Confidential) Name: Date of Birth: Age: Referred by: Psychologist: Place of Examination: Date of Examination: Date of Report: * Examiner:

Align demographic data here * * * * * * *

Reason for Referral: (Typically, to clarify diagnosis, to assist in differential diagnosis, to assist in treatment planning, to answer a particular question or set of questions. Before beginning any assessment, clarify the questions to be answered by the assessment. Include the client's questions, as well as those of third parties. The clearer the reason for the assessment is, the more helpful you can be to the client.) Procedures: (List any procedures completed, in order of istration. In the standard battery, the order given below is the typical, “peel the onion” order. For Cognitive Assessment, include as “Clinical Interview” the collection of background information. The standard battery consists of those tests marked with a *.) Clinical Interview* Wechsler Adult Intelligence Scale -III (WAIS-III)* or Wechsler Intelligence Scale for Children – IV (WISC-IV)* Bender-Gestalt Test* House-Tree-Person* Incomplete Sentences Blank* Minnesota Multiphasic Personality Inventory -2 (MMPI-2)* Thematic Apperception Test (TAT)* Rorschach Inkblot Method* Life Style Inventory Others as needed to answer the referral question Background Information: Identify the sources of information, and an assessment of their reliability as sources. Include here information regarding the following topics: Identifying information including age, gender, ethnocultural identity, marital status, and occupation or academic role. Prior psychological assessment. Presenting complaint and symptoms. History of the presenting complaint including onset, duration, course (times when it’s better or worse), prior

treatment efforts and success of these, client's conceptualization of the problem. Other personal, academic, work, medical, social, or family history relevant to the referral question, presenting complaints, or diagnoses under consideration. Other psychological/ psychiatric problems in the family history. (Note: Do not name family . Refer to them by relationship only. E.g., “Mr. X’s uncle” versus, “John Smith, Mr. X’s uncle”; “older brother” versus “Tom Smith”, Mr. X’s older brother”.) Also include: reports of substance abuse: what, how recently, how often, how long. Medication use: what medication, dose, when last dose was taken, what it is for. Behavioral Observations: This section should describe what the client brings to the testing. They represent your clinical observations apart from the test situation itself. These are not diagnostic conclusions. Keep it descriptive, not evaluative or conclusive. This section also does not include the client's response to specific test stimuli. That belongs under "results". To clarify, “The client became increasingly anxious as testing progressed, and refused to complete the Arithmetic subtest” does belong here, as it describes the client’s anxious state. “The client laughed upon being presented with set 4 of the Picture Arrangement subtest, saying it reminded her of her mother” does not belong here (if, indeed, it is useful at all!) because it is a response to a specific test item. In addition, “The client appeared to be using a sensory approach to Matrix Reasoning,” belongs under test results because it indicates not a state, but an approach to the particular task. Finally, “The client appeared to be suffering from a generalized anxiety,” is a diagnostic conclusion, and belongs at the end of the report, after test results (the data that informs the conclusion) have been presented. DO include here the following: Setting constraints on testing (e.g., two or more sessions, interference, etc.). Mental Status information, including appearance if noteworthy or related to referral question. Orientation to person, place and time, especially in settings where that might be in question, such as psychiatric, forensic, or rehabilitation/ neurological settings. Ideation evident in behavior, such as suicidal/ homicidal comments, evidence of delusional or hallucinatory thinking evident in behavior (as opposed to evident in test results). Speech quality, e.g., intonation, modulation, pressure, fluidity, speech problems. Apparent mood (that is, affect) during testing. Handicaps: glasses or s (to correct what?), hearing aid, gait or motor problems, hand tremors, etc. Cooperation, persistence, effort. Make a statement here about the validity of results based on behavioral observations and history. For example, you could say, "Based on Mr. X's behavior, and his apparent effort and cooperation, test results are likely to (be an accurate assessment of, underestimate) his (typical functioning, functioning at this time, or potential)". Note the parentheses. They suggest alternatives. Note especially the last set. “Typical functioning” means you think this is the way the client functions generally, and that the test results are not unduly influenced by situational factors. “Current functioning” means this is

the way the client is functioning NOW, but the results may not indicate prior functioning or predict future functioning. This is appropriate when, for example, you are testing a person who is recovering from brain injury, or who is severely depressed. “Potential” indicates you are trying to predict how the person will function in the future, such as on the job, or in school. For example, you might be evaluating a student for special services, and the test results may reflect about how well the student can be expected to perform at his/her best (provided you were able to motivate the student to perform well, and there were no situational or personal constraints). Some examples: “Based upon Johnny’s obvious cooperation, persistence, and effort, these tests results are likely to accurately reflect his true potential.” “Based upon Johnny’s lack of cooperation and difficulty with concentration and persistence, these results likely underestimate his true potential. However, they may accurately reflect his functioning under the current stress of family disruption.” “Based upon Mrs. Smith’s effort, concentration, and cooperation, these results likely accurately reflect her current depressed functioning.” “Based upon the number of interruptions and the less than optimal testing conditions, these results likely underestimate Ms. Jones’ true score, despite her cooperation, effort, and obvious desire to succeed.” “These test results may slightly overestimate Mr. Smith’s true score, particularly on Performance tasks, due to his familiarity with the test materials.” “Mr. Smith’s history, and his cooperation with the testing procedure, suggest that the results reflect his typical functioning.” Cognitive Functioning: (Select appropriate phrases. Note: here and throughout, underlines are space holders. Do not use underlining in the report itself.) (Mr./Mrs./Ms. X)'s performance on the WAIS-3 places him/her within the (average/ above average/ superior/ borderline/ extremely low) range of intellectual functioning. (His/Her) Full Scale IQ of ___ is higher than that of ____% of individuals (his/her) age. (This last statistic is called a percentile rank. Don’t confuse it with being “95% sure of your results”) An IQ of 90 to 110 is average. Were (s/he) tested again under similar circumstances; there is a 95% chance that (his/her) score would fall between ___ and ___. (The last phrase is the “confidence interval.” You are 95% confident that the person’s “true score” falls within the given interval of scores. Follow that pattern in reporting VIQ and PIQ scores, but abbreviate it as follows.) Mr./Mrs./Ms. X earned a

VIQ of ___ (_*_%, ___-____), and a PIQ of ___ (_*_%, ____-____). (The * is the percentile rank for the score.) The __ point difference between (Mr./Mrs./Ms)'s VIQ and PIQ (is/is not) significant. ( that if it is not statistically significant, it is not likely to be clinically significant, under most circumstances. That means if the difference is too small to detect with precise statistics, it is unlikely to be detectable by the naked eye, and thus have any meaning in describing the person’s behavior. Therefore, if there is no statistical difference, you treat the scores as identical. In addition, there is no such thing as “almost” statistically significant. It either is or is not. So, do not interpret as useful, distinguishing, or relevant a difference that approaches but does not equal or sur the cut off for significance!) Next, discuss implications of the difference, if any exists. The WAIS-III also yields the following Index Scores and subtest scales scores. Index scores of 90 to 110 and scaled scores of 8 to 12 are average. (Mr./Mrs./Ms. X) obtained the following scores. Verbal Comprehension Vocabulary Similarities Information Comprehension Working Memory Arithmetic Digit Span Letter-Number Sequencing

Score %ile Range ___ __ __-__ Perceptual Organization __ Picture Completion __ Block Design __ Matrix Reasoning __ Picture Arrangement Object Assembly ___ __ __ __

__

__

Score %ile Range ___ __ __ __ __ __ __ __

Processing Speed

___

Digit-Symbol/Coding Symbol Search

__ __

__

__

The FSIQ accurately reflects the person’s overall IQ only insofar as it reflects a unified construct. If VIQ and PIQ are significantly divergent, the meaning of the FSIQ is in doubt. Similarly, VIQ and PIQ are useful constructs only if their component index scores are comparable. (In the next iteration of the WAIS, VIQ and PIQ will be eliminated. VCI and POI are more pure measures of verbal and visual-motor functioning. Compare these as you would VIQ and PIQ.) Working down the hierarchy, each index score is meaningful as a construct only if the subtests that make up that measure “hang together” statistically. Discuss meaning of X's scores and their comparisons from the discrepancy analysis page of the WAIS-III record form using that hierarchy. Discuss both which scores are statistically high, low or average compared to the general population (nomothetic comparison), and which scores are

strengths or weaknesses when compared to the client’s overall functioning (idiographic comparison). When discussing Working Memory, discuss the meaning of Digits Forward and Digits Backward, if significant or relevant. Address the assessment of incidental memory from Digit Symbol - and the recall portion of Bender. Differentiate poor performance on Coding due to motor vs. incidental memory. At the bottom of the hierarchy, each subtest accurately assesses performance on its construct to the extent that intra-subtest scatter is minimal. Discuss any scatter. Look for patterns in “hits and misses.” E.g., does the person miss all geography questions on the Information subtest? All division problems on Arithmetic? Discuss the implications of any such patterns. Continue your report by discussing the results of any other achievement or cognitive testing. There are more useful - and less useful - ways to present achievement test results. If you are istering these, come talk with me, and I’ll help you identify methods that highlight underlying cognitive processes. Discuss the implications of such results. Compare with WAIS-III results, and discuss the implications of the differences. Do not diagnose specific learning disability from ability and achievement test comparisons alone, but point to what the differences suggest, including whether additional assessment is needed. Bear in mind that learning disability assessment requires both an abilityachievement discrepancy and deficits in some underlying cognitive process. Pay attention, therefore, to the underlying processes assessed in all instruments, as, for example, the index scores on the Wechsler. Include relevant findings from the MSE, Bender, House-Tree-Person, and Sentence Completion, TAT, Rorschach, etc. (Neurologically intact or not according to Koppitz’s and/or Lacks’ criteria, construction complexity on HTP and/or results of DAP scoring of person drawing; presence of cognitive, motor, or perceptual problems on the Bender, HTP; number and complexity of responses on the Rorschach; vocabulary usage, fluency of language, evidence of learning disabilities or higher intelligence in content, grammar, spelling, punctuation, etc.) Resolve any discrepancies in the data by identifying the differences or similarities in the constructs being measured, setting or client characteristics, or task demands. For example, memory tested using sentence recall, digit recall, kinesthetic recall, and visual recall may differ, as may free recall versus cued recall. (E.g., do you prefer multiple choice, or fill-inthe-blank tests?) Note unusual behavioral responses to test stimuli, or to the testing situation itself, particularly unusual responses. Alternately, note normal responses when the unusual would be expected. For example, an allegedly hyperactive child attends, persists, concentrates, and so forth (might be effect of medication, misdiagnosis, or…) Describe any information gained or performance differences observed from testing the limits (and describe the method of testing of the limits!).

Try to translate all of this into general . What do strengths and weaknesses in the above areas look like in this person’s everyday life? How are they connected to the presenting problem or other reason for referral? Sum up this section by discussing the implications of the results. What do they say about the client’s overall cognitive functioning and cognitive style? Social-Emotional Functioning Discuss the implications of the person's cognitive strengths, weaknesses, and style for daily functioning. Address the person's capacity to appreciate reality and control irrationality, his/her judgment and empathic ability. Identify the person's primary psychological symptoms, if any. What is the nature of the person's anxiety? Under what circumstances does the person manifest anxiety? How is the anxiety manifested? How does the person attempt to cope with anxiety, stress, and the current situation? How effective are these methods for him/her? Discuss the person's capacity for appropriate (not too lax, not too harsh) impulse control. Identify the person's predominant affect and mood. Discuss the person’s degree of responsiveness to affective stimuli, his/her range of affect, and its appropriateness to the situation. Identify the cognitive, social-emotional, situational (and biological, if applicable) factors that underlie the presenting problem, if any, or that relate to the referral question. Relate the above to the person's lifestyle, presenting problems, and social, academic/ occupational, interpersonal, and family functioning. Identify the person's view of self, world, others, future. Relate these to the life tasks of work, love, community/friendship (and self and spirituality). What are the core beliefs that affect the person’s functioning, especially those relevant to the referral question? Identify the areas in which the person demonstrates psychological strength and positive qualities. Relate these to the presenting problem and/or referral question. Summary: Briefly summarize the report as a whole. Some audiences (judges, busy psychiatrists) read only the summary, so you must be succinct, clear, and direct. Start with a generalized mention of intelligence testing results, giving the level of intelligence, and any noteworthy strengths, weaknesses, or stylistic patterns observed. Then summarize overall personality assessment results, highlighting the more central and salient aspects of the person’s “ality” and his/her current functioning. Clearly and simply relate the results to the referral question, and ANSWER THE QUESTION in as straightforward and clear a manner as possible. Make sure your answer

is clearly ed by the test data. Give MUCH more weight to the data and to actuarial interpretation of results than to your “clinical impressions.” Where there is conflict between clinical impression and data, say so, and identify which is which. NOTE: Information and hypotheses listed in the summary should reflect PREVIOUSLY DISCUSSED information and hypotheses. No new information or hypotheses should be presented here. Again, CLEARLY ANSWER the referral question. Diagnosis: Note that for some referral questions, diagnosis is not the issue, and no diagnosis should be given. For example, pre-employment screening does not require a diagnosis. For purposes of the assessment sequence and qualifying exams, full, 5-axis diagnoses must be given. Axis I: XXX.XX (Write out diagnosis and modifiers for Axes I and II Axis II: XXX.XX in addition to their codes.) Axis III: (Medical conditions that impact on the referral question, if any. Note the source of the information, such as medical file, patient report, or client’s physician, or “per DSM-IV criteria”. Failure to cite the source can leave you open to charges of practicing medicine without a license, because you are not qualified to make medical diagnoses. ) Axis IV: (Psychosocial stressors: list specific stressors, and identify them as mild, moderate, severe or extreme. Note that the rating is by objective criteria. Adjusting to a new school is usually a mild stressor, but may become moderate is preceded by a move at a vulnerable age or by a complication such as coping with peer reaction to a physical disability, or may be more severe if it comes as a result of some trauma.) Axis V: GAF Current: __ GAF Highest in past year: __ (Note that a person’s current level of adaptive functioning cannot exceed his/her highest level of functioning in the past year, since the day you assessed him/her is a part of the past year!) Recommendations: (Use whichever apply of those below, and/or additional or alternative ones pertinent to the referral question.) 1. Identify whether psychological treatment is warranted. If so, related to what specific issues? What mode? What kind? What frequency, intensity, setting, and urgency? To achieve what goals? Of what expected duration? Example: “Continued inpatient hospitalization is warranted due to Mr. Smith’s suicidal ideation and plan, concurrent severe anxiety and lack of social .”

“Individual, outpatient, cognitive-behavioral therapy, once weekly, to address Ms. Jones’ adjustment to college and separation anxiety is recommended. Ms. Jones should begin working with the college counselor this week if possible, as she is considering terminating her enrollment and returning home.” “Ms. Smith should be referred to Kinheart for participation in “coming out” groups to help her identify and cope with the issues related to her decision to reveal her sexual orientation to her family, and to receive from others after having been “outed” at work.” 2. Consider medical evaluation? To alleviate what symptoms? Example: “If Ms. Jones’ anxiety does not abate within two weeks, the Campus Health Care Center should schedule Ms. Jones for a medical evaluation to determine whether antianxiety mediation is needed. Specific attention should be paid to evaluating her sleep pattern at that time, as she reports sleep deprivation due to excessive worry at night.” 3. Further assessment? What kind? By whom (what specialty)? To resolve what questions? Example: “Neuropsychological assessment is recommended to assess the extent and nature of brain damage Mr. Smith has suffered as a result of his substance abuse. Rehabilitation evaluation is recommended to identify interventions that may help him cope with his impairments.” 4. Non-psychological, non-psychiatric interventions needed? What kind? By whom? Other agencies need to be involved? Example: “Given the nature of Mrs. Smith’s cultural and religious beliefs, and their impact on her willingness to seek therapy, consultation with and/or referral to her rabbi is recommended. This consultation should identify whether the rabbi is capable of helping Mrs. Smith with her depression, or whether the rabbi can assist her in accepting the professional help she clearly needs.” 5. Environmental interventions needed? Example: “Johnny needs to be seated at the front of each classroom, so that he is able to see the board.”

“This employee should be switched to a position that minimizes interaction with customers, and provides him with opportunity to socialize with a small cadre of fellow workers.” 6. Issues that might interfere with treatment and how to address them? Example: “Ms. Jones’ parents see her as a victim of the university’s “impersonal, uncaring environment.” They repeatedly sympathize with and encourage Ms Jones’ distress. Unless the parents can be helped to adopt a ive yet adaptive approach, this student may fail in her transition to college. It is recommended that the Dean of Students arrange to meet with the parents and that they be referred to the Parents-in-Transition outreach program.” Finally, include a formal signature block, which looks like this: Respectfully submitted,

________________________________ Your name, highest EARNED and RELEVANT degree Examiner (or Psychology Intern)

________________________ Dr. First Last Supervisor

Ethical guidelines specify that you should list only your highest degree (or two if relevant, such as J.D., Psy.D. if you practice mental health law). This means that your Ph.D. in economics, English, or even education (unless it’s school psychology) are not to be listed. Even your M.D. or R.N. are irrelevant, because they did not train you to perform psychological testing/assessment. For purposes of your education in psychology, you should list ONLY your M.A. in a related mental health field. In addition, it is expressly prohibited to list yourself as “Psy.D. Candidate”. Professional schools do not recognize or use the term. Traditionally, the term is reserved for persons who have completed everything for the doctoral degree except for the dissertation, and whose dissertation proposals have been accepted. Because the path to the Psy.D. varies from the path to the Ph.D., ISPP does not use or endorse the term. Do not use it!