Psychological Evaluation Report
A psychological evaluation report is a comprehensive document that outlines the results of a psychological assessment conducted by a licensed psychologist or mental health professional. This report typically includes the following sections:
Identifying Information: This section provides basic details about the individual being evaluated, such as name, age, gender, date of birth, and the date of the evaluation.
Reason for Referral: This section explains why the individual was referred for a psychological evaluation. It may include concerns raised by the individual, family members, educators, or healthcare providers.
Background Information: This section provides a detailed history of the individual, including developmental, medical, educational, social, and family history. It may also include information about past psychological or psychiatric treatment.
Assessment Procedures: This section lists the specific tests, interviews, and other methods used during the evaluation. Common assessments might include intelligence tests, personality inventories, behavioral checklists, and clinical interviews.
Behavioral Observations: This section describes the individual's behavior during the evaluation, including their appearance, mood, affect, speech, and interaction with the evaluator.
Test Results and Interpretation: This section presents the results of the psychological tests administered. It includes raw scores, percentile ranks, and interpretations of what these scores mean in the context of the individual's overall functioning.
Diagnostic Impressions: Based on the assessment, this section provides a formal diagnosis (if applicable) according to the criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM) or other diagnostic frameworks.
Summary and Recommendations: This section summarizes the key findings of the evaluation and provides recommendations for treatment, interventions, or further assessments. Recommendations may include therapy, medication, educational accommodations, or referrals to other specialists.
Signature and Credentials: The report is typically signed by the psychologist or mental health professional who conducted the evaluation, along with their credentials and license number.
Example of a Psychological Evaluation Report:
Identifying Information:
Reason for Referral: John was referred for a psychological evaluation by his primary care physician due to concerns about persistent anxiety and difficulty concentrating at work.
Background Information: John is a 25-year-old male who reports a history of anxiety since adolescence. He has no significant medical history but reports a family history of anxiety disorders. John graduated from college with a degree in business and is currently employed as a marketing analyst.
Assessment Procedures:
Behavioral Observations: John presented as a well-groomed, articulate individual. He appeared anxious during the interview, frequently fidgeting and avoiding eye contact. His speech was clear and coherent, though he occasionally paused to collect his thoughts.
Test Results and Interpretation:
Diagnostic Impressions:
Summary and Recommendations: John exhibits significant symptoms of anxiety and mild depression, which are impacting his daily functioning. It is recommended that John begin cognitive-behavioral therapy (CBT) to address his anxiety and depressive symptoms. A referral to a psychiatrist for a medication evaluation is also recommended. Additionally, John may benefit from stress management techniques and regular exercise.
Signature and Credentials: Dr. Jane Smith, PhD, Licensed Clinical Psychologist License Number: PSY12345
This report is intended to provide a comprehensive understanding of the individual's psychological functioning and to guide appropriate interventions and support.