(FACILITY NAME) – optional/ you may want to invent your own name and logo
PSYCHOLOGICAL EVALUATION REPORT
Name :
Address :
Age :
Gender :
Civil Status :
Education :
Dates of Evaluation :
Date of Report :
PURPOSE FOR EVALUATION:
Briefly introduce the client and the problem. Begin with a concise "demographic
picture" of the client. Example: This is the first referral for this 32 year old, single, female
who has 13 years of formal education and is employed as a beautician. She was referred
due to symptoms of depression.)
If you have a referral question, address it. Don't just copy the question from the referral
sheet.
State the "Purpose of the Evaluation."
Use this section to tell your reader what issues you will address in the body of the
report. In this section you can "pose a question" which you will answer in the
"SUMMARY" section.
Example: The purpose for the current evaluation was to screen for symptoms and clarify
the nature of the underlying depressive mode.
Word the referral question to cue the reader as to what confirming/refuting data to
focus on while reading the report.
Address unwritten needs of referral source, such as objective confirmation of diagnosis,
presence/absence of risk factors for aggression, suicide, etc.
Since this is for educational purposes, you may want to indicate for self-knowledge
ASSESSMENT PROCEDURES: write this in table form with name of test, date administered
Referring to this section as "ASSESSMENT PROCEDURES" allows you to include the
Mental Status Exam and the Clinical Interview as two of your procedures. This helps
communicate to the referral sources that you do more than give some tests and copy
interpretive statements out of a manual. It lets them know that your evaluation is a
professional integration of information from a variety of sources.
Note who gave the tests and how long it took. These issues are important if a case ever
goes to court.
Examples of Assessment Procedures:
o Mental Status Examination
o Psychosocial History
o Millon Clinical Multiaxial Inventory-III (MCMI-III)
o Basic Personality Inventory
o Marital Satisfaction Inventory
o Johnson Taylor Temperament Analysis
o Thematic Apperception Test
o Projective Drawings
o Luscher Color Test
o Interview with …
o This client participated in 3 hours of testing and a 1 hour diagnostic
interview. Tests were administered by …
BACKGROUND INFORMATION:
At the beginning of the Background Information section, give a concise demographic
description of the client.
Present paragraphs dealing with family, social, legal, medical, family, mental health, etc.
issues, if needed. Only include those issues that are relevant to the "questions" posed
under "PURPOSE FOR EVALUATION". Excessive, unnecessary details will distract the
reader from the case you are trying to build in support of your conclusions!
Whenever possible, MAINTAIN CHRONOLOGICAL ORDER when presenting background
information.
Next describe the client's history of substance abuse/mental problems, and mental
health care in CHRONOLOGICAL order. Were possible, provide enough details of prior
intervention efforts to clarify what was attempted and whether it was successful. Also,
be sure to describe the client's behavior and level of adaptive functioning BETWEEN
prior interventions. (These details will help give the treatment team an idea of what
"target level" of adaptive functioning to shoot for in the current intervention.)
Follow with a paragraph describing the onset and development of the present illness/
exacerbation.
End this section with a brief paragraph summarizing staff observations, client behavior,
level of motivation, etc. during the evaluation. Keep in mind that objective observations
by professional staff are one of your best sources of data.
In any, conclude with a sentence indicating medications being taken at the time of
testing.
Present the details in a meaningful, orderly, and functional manner.
Group related pieces of information together.
Use good paragraph structure.
o The first sentence of the paragraph tells what the whole paragraph is about.
o The last sentence sums up the paragraph.
Keep information under the appropriate subheading.
Don't put Mental Status details or behavioral observations under Background
Information, or vice versa.
Report information clearly and with confidence.
Avoid excessive use of words like "reportedly; according to the client; or the client
stated." Once you've made it clear that the history came from the clinical interview, you
don't need to repeatedly qualify the data. One way to avoid this is to use quotation
marks occasionally to let the reader know you are relating the client's opinions.
Qualifiers are important at times, but excessive use reveals indecision or
uncertainty. Avoid excess use of "appears to, suggests, may be, apparently, etc".
Rather, say "The client is..." Use of behavioral descriptors can help here. For example:
(WEAK) The client may have conflicts dealing with authority figures.
(BETTER) The client's difficulty with authority figures is evident in his multiple expulsions
from school, arrests, and frequent loss of jobs due to "personality conflicts" with
employers.
Include only details that are relevant to your conclusions. Excess details distract the
reader from the case you are building in support of your conclusions. For an avoidant
personality disorder, you might spend several paragraphs on family and other
interpersonal issues, while devoting only a couple of sentences to prior
treatment. Remember, the purpose of the psychological report is usually NOT to provide
a comprehensive social or medical history. Include only relevant details.
Generally, don't repeat information. If paragraph one stated that the client has been
repeatedly fired from jobs, don't repeat this in paragraph four as part of the "social
issues" paragraph. Find a way to convey all the information and only say it
once. Exceptions to this rule include repetition for emphasis and limited repetition in
the summary.
MENTAL STATUS EXAMINATION:
Focus on YOUR observations and impressions. This section of the report should focus on
your objective evaluation. Avoid quoting the client's opinion of his own mood, affect,
etc. It's also best to avoid mixing in background information or test information with this
section.
For example: Results of mental status examination revealed an alert, attentive individual
who showed no evidence of excessive distractibility and tracked conversation well. The
client was casually dressed and groomed. Orientation was intact for person, time and
place. Eye contact was appropriate. There was no abnormality of gait, posture or
deportment. Speech functions were appropriate for rate, volume, prosody, and fluency.
Vocabulary and grammar skills were suggestive of intellectual functioning within the
average range.
The client's attitude was open and cooperative. His mood was ethymic. Affect was
appropriate to verbal content and showed broad range. Memory functions were grossly
intact with respect to immediate and remote recall of events and factual information.
His thought process was intact, goal oriented, and well organized. Thought content
revealed no evidence of delusions, paranoia, or suicidal/homicidal ideation. There was
no evidence of perceptual disorder. His level of personal insight appeared to be good, as
evidenced by his ability to identify specific stressors that precipitated the current
exacerbation. Social judgment appeared good, as evidenced by appropriate interactions
with staff and by cooperative efforts to achieve treatment goals.
RESULTS OF EVALUATION: or CLINICAL IMPRESSION:
The Hypothesis Testing Model is recommended. In this model results are focused on
possible answers to the referral question(s). The idea is to present a hypothesis in the
"PURPOSE FOR EVALUATION" section, then present data systematically to support or
refute the hypothesis.
Separate paragraphs in the "RESULTS OF EVALUATION" section address theoretical/
conceptual issues by integrating data from the history, mental status exam and
behavioral observations with data from all the tests.
Specific tests are rarely mentioned by name.
The strength of this model lies in its efficiency and concise focus on the referral
problem. The reader isn't distracted by unrelated details. The primary weakness of the
model is that you don't report some of the information which is unrelated to the
"PURPOSE FOR EVALUATION" but which could potentially be useful to other disciplines.
For example: Results of this evaluation reveal the presence of an Avoidant Personality
Disorder, as evidenced by (list the relevant DSM criteria). This client displays a chronic
inability to establish and maintain satisfactory interpersonal relationships (or to
maintain employment). He is relatively anxious individual who experiences marked
internal conflicts over dependency issues. He has intense, unmet needs for attention
and affection. However, his emotionally abusive childhood has led to extreme fear of
rejection or humiliation in interpersonal relationships. His cool, detached public
presentation represents a defensive effort to shield himself from emotional pain.
CONCLUSION/SUMMARY/RECOMMENDATIONS:
Begin by specifically answering the questions you posed under "PURPOSE FOR
EVALUATION." Then elaborate as much as needed to present your conceptualization of
the case.
It's fine to include DSM diagnostic impressions, but your summary of the client's
psychological makeup is far more important. If you do include DSM labels, be sure
you've provided enough detail in the body of the report to support the diagnostic
criteria as described in DSM.
Any recommendations for treatment can also go here.
The uniqueness of psychology centers around our theories and efforts to make sense
out of the distorted clinical picture.
For example: Results of this evaluation reveal the presence of an Avoidant Personality
Disorder.
Sign the report
______________________
(Your name)
(Professional Title)
(Licensure Title & #)
ADDITIONAL POINTERS
Tailor the report to the reader with respect to his training, his familiarity with terms,
uses for the report, and what questions he is asking.
Avoid using jargon or terms for which there is little consensus as to their meaning. State
what you observe rather than just saying “....impaired reality testing", or that the client
appeared "characterological", "neurotic", or that he displayed "cognitive slippage", or
"perceptual insensitivity."
Referring to yourself in a report: There is no clear consensus whether you should use
personal pronouns or refer to yourself as "the examiner." Many psychologists feel that
referring to yourself in the third person makes the report sound more objective and
formal. Others (including myself) feel that it makes the report sound awkward and
stilted. One option is to find ways to avoid references to yourself. For example:
(WEAK) The Client was angry with me for interrupting his scheduled activities on the
ward.
(BETTER) The Client voiced frustration and hostility over disruption of
scheduled ward activities.
Vary your sentence structure throwing in some dependent clauses. This will make the
report more readable. However, it's best not to get so "flowery" that it is hard to
understand. You don't want the reader to have to reread a sentence to figure out what
you are talking about. For example:
(WEAK) Never having attained gainful employment, the client, a precocious,
intellectually gifted, young man who dropped out of school after fifth grade owing to
personality conflicts with his geography teacher, a demanding, overly critical authority
figure, is excessively resentful of external demands.
(BETTER) Despite his superior intellectual ability, the client's excessive resentment for
authority figures and external demands has led to chronic impairment of academic and
vocational success.
Grammar and sentence structure:
o Maintain tense, at least throughout sentences, and preferably throughout
sections of the report.
o Discussion of actual test performance is in past tense (what the person did).
o Discussion of abilities can be in present tense (what the person is like).
Focus: The reader can handle only two or three main points. While you might be able to
say much more, most readers will benefit more from a briefer report that is clear about
the most important aspects. Of course, richness and breadth is great if the relevance to
the main points is obvious.
Interpret, don't just describe: You are the expert. Therefore, don't take the easy (but
dangerous) way out by presenting a lot of facts and leaving it up to your reader to
decide what they mean. Similarly, don't just list several hypotheses without some
guidance about support for each.
Relate data to functioning: The characteristics measured by most scales are rather
removed from daily tasks. Try to bring the skills back to the domain of what the client
must do in life. Also, part of interpreting is to draw implications. You can help make
implications clear to your reader by predicting performance in relevant domains. Make
sure you bring the data back to practical application that the reader can use.
Capture the person: Remember, you are talking about a real person. If you think how
your favorite novelist lays out a character, you will recognize that a rich, interesting
description really works. An interesting report with relevant examples, as opposed to
the more common sterile/clinical report that focuses on scores, grabs the readers’
attention and communicates more. Ask yourself if a parent or good friend of the client
would see that person in your report.
