Assessment Report

Demographic Information

Name: Olive Black

DOB: 02-22-2002

Address: 123 Upthe Road, Mansfield, PA

Gender: Female

Phone: 555-555-5555

Ethnicity: White (non-Hispanic)

Email: ihategreenolives!@hotmail.com

Date of Interview: 11-04-2020

Name of Interviewer: Madison Welsted

Presenting Problem or Reason for Referral

Olive Black is an 18-year-old white female of average height and average build. She was self-

referred to the Mansfield University Counseling Center for assessment and counseling related to

her high levels of anxiety, potential physical anxiety-related symptoms, feelings of isolation, and

her inability to relax. Ms. Black reported that she has been finding it increasingly difficult to

manage her anxious thoughts while in her dorm room. Since she moved into her dorm room, she

has been experiencing more severe headaches as well. She stated that she is fearful of her

symptoms worsening and affecting her ability to complete schoolwork if she cannot gain control

over her anxiety. Ms. Black was very open to discussing her situation and stated that she is
willing to follow the recommendations necessary to improve her quality of life. An assessment

was conducted to determine differential diagnosis and best course of treatment.

Family Background

Ms. Black was raised in Hallstead, PA. She is the oldest of four siblings. The brother that she

shares both parents with is a high school junior. Her two half-brothers are eight-year-old twins,

and they share the same mother but not the same father. Her father is a mechanic, and her mother

currently works in an agricultural family business, although her work history also involves years

of waitressing and other jobs.

Ms. Black notes that her father was verbally abusive towards her oldest brother, but not towards

her. Ms. Black’s parents divorced when she was nine years old, and she expresses that this was a

difficult time in her family’s life. During this time, her mother lived with the father of the twin

brothers, and she notes that her mother’s relationship with him became verbally abusive. She

moved back and forth between her parents’ homes, and often did not have a consistent visitation

schedule.

Currently, Ms. Black’s mother lives without a significant other. Years after the divorce, Ms.

Black’s father re-married and her stepmother became a part of her life. She notes that her father

and stepmother have controlling parenting styles and that her oldest brother and she both struggle

with this. Currently, she is in a relationship with a 19-year-old male significant other that has

lasted for a year and a half thus far.

Significant Medical/Counseling History

Ms. Black reported that she began visiting her elementary school counselor shortly after her

parents divorced. She noted that she was referred by her teacher for this counseling because of a
paper she wrote in her class which mentioned that she “was very sad and my father was too.”

Outside of school, Ms. Black remembers seeing counselors with her family during the divorce

time period as well. She continued visiting with counselors until sixth grade.

In high school, Ms. Black made the decision to go back to counseling on her own. She visited

two different counselors from ninth to eleventh grade. She explained that she made this decision

because she felt that her relationship with her parents and with her significant other at the time

were not healthy. She also noted that she never fully finished her treatment plans with any

counselors that she sought out on her own.

Ms. Black reported that she was diagnosed with a minor concussion after visiting the doctor

about her recurring headaches in ninth grade. During this time, she only went to school for half-

days and limited her screen time. Her headaches were not as severe after this treatment. Ms.

Black said that she did not believe she had a concussion, but instead, that she was “working too

hard at school and just needed to take more breaks.” She said she believes her headaches

subsided during this time because she was forced to “relax and stop overworking.”

Ms. Black reports that she currently suffers from headaches and that they are more severe during

stressful periods.

Substance Use and Abuse

Ms. Black said she has never used any illegal substances and she has only consumed alcohol on a

few special occasions. She says she worries about consuming alcohol because she believes her

father is an alcoholic and does not wish to become one herself. She says she “never sees him

without an alcoholic drink nearby.” She also reported that many of her extended family members
consume alcohol regularly, and she did not enjoy being in their presence when alcohol was

involved.

Educational and Vocational History

Ms. Black attended public school from kindergarten to second grade. She was tested for

giftedness twice during this time at the urge of her parents, but did not meet the requirements. In

third grade, she was charter schooled. Ms. Black notes that the reasoning for being charter

schooled was because her parents thought it would be a better academic challenge for her.

However, she did not enjoy it and found it too difficult, so she returned to public school.

Between fourth and fifth grade, Ms. Black was tested for giftedness again, and she was

determined to be a gifted student. In the middle of fifth grade, she switched public schools due to

family living situations with divorce. She remained at the new public school until the end of

sixth grade. She then returned to her original public school for the duration of middle school and

high school. Throughout her education, Ms. Black noted that teachers often thought very highly

of her. She said that achieved mostly straight A grades and she earned the salutatorian title in her

senior year of high school.

Ms. Black is a first semester psychology major. She chose psychology because of her own

experiences with counseling and her strong desire to help others. After she completes her

undergraduate degree, she plans to earn a master’s degree in social work and a counseling license

so that she can become a mental health counselor. She said she is currently doing very well in

her classes academically, but often “feels stressed and burned out with the workload.”

The only employment Ms. Black reported is her part-time job in food service. At this job, she is

required to make sandwiches, bake, clean, provide customer service, and occasionally manage
paperwork. She began this job in high school so that she could save for college, and plans to

return when she is on school breaks. She reported that the job can be very stressful, but that she

enjoys the challenge, and it has helped her develop better public communication skills.

Other Pertinent Information

Ms. Black reported that in the past she had limited her food intake so that she would not gain

weight. She also disclosed that she occasionally made herself throw up when she felt that she had

eaten too much. Ms. Black does not feel that these issues are relevant to her now, although she

has never received professional treatment or counseling for these experiences.

Ms. Black expressed having difficulties establishing friendships. She said that she finds it hard to

make plans with friends, and that many times when she does make plans, she cancels them or

dreads following through with them. She said that this has contributed to her feelings of

isolation.

Mental Status Exam

Ms. Black arrived on time for her appointment and was appropriately dressed in leggings, and a

long, knit sweater. Her hygiene and grooming were adequate. Her eye contact was highly

inconsistent, she was wringing her hands throughout the duration of the interview, and her body

posture was slumped. Her affect was anxious which was consistent with her reported mood. Her

verbal expression suggested at least average intelligence, if not above average intelligence. No

difficulties with memory, comprehension, or judgment were noted. She was oriented to person,

place, and time. She denied experiencing psychotic symptoms, suicidal ideation, and homicidal

ideation. She reported that her main concerns were her general physical symptoms associated
with anxiety and her anxious thoughts that were negatively affecting her quality of life in daily

activities and causing her high levels of stress.

Test Results

The following tests were administered: Shipley Institute of Living Scales, IQ test online at

IQtest.com, Great British Intelligence Test, Emotional Intelligence Quiz, Procrastination Scale,

Stress Scale, Interpersonal Behavioral Inventory (IBI), State-Trait Anxiety Inventory, Anxiety

Test at anxietycentre.com, Manifest Anxiety Scale, Achievement Anxiety Test, Beck Depression

Inventory, Major Depression Inventory, Myers-Briggs Personality Profile, IPIP-NEO Big Five

Test, Locus of Control Scale, Eysenck Personality Questionnaire – Extraversion items, Revised

Cheek and Buss Shyness Scale, SCOFF Questionnaire, and Incomplete Sentence Blanks.

Cognitive Abilities

Measures of intelligence included the Shipley Institute of Living Scales which showed a

Vocabulary score that converts to a deviation Intelligence Quotient (dIQ) of 100 and a Reasoning

dIQ of 118. Her Overall dIQ was 113.5. Her Vocabulary and Overall scores fall in the average

range, while her Reasoning score falls in the above average range. Ms. Black’s score on the

IQ.com test was 122, which is in the above average range. Ms. Black said that she did not feel

confident in the accuracy of this test because she was “mostly guessing towards the end.” On the

more comprehensive Great British Intelligence Test, she scored in the upper 20% on Verbal

Working Memory, Spatial Working Memory, and Mental Rotation. She scored in the upper 30%

on Emotional Discrimination, the upper 40% on Attention, and the upper 50% on Verbal

Reasoning. She fell in the lower 50% on short-term and medium-term Prospective Memory,

Spatial Intelligence, Planning, Verbal Comprehension, and Spatial Reasoning. The Emotional IQ
test measures the ability of an individual to recognize, understand, and manage his/her own

emotions as well as the emotions of others. Ms. Black’s score on the Emotional IQ test was 120,

which falls in the above average range, and indicates that she is highly aware of her own

emotions, has sensitivity to emotional signals, and is in tune to the emotions of others.

The profile suggests her strengths are in most verbal tasks, and that she may have difficulty with

tasks that require high short-term or medium-term memory ability and some nonverbal tasks. Her

performance on Emotional Discrimination and the Emotional IQ test suggest strength in reading

emotions of others based on their facial expression and strength in internal emotional awareness.

Her good reasoning abilities are indicated especially by her high Reasoning score on the Shipley

Institute of Living Scales and her high Verbal Reasoning score on the Great British Intelligence

test. Overall, academic and cognitive tests do not indicate any significant learning difficulties

that might negatively affect her school performance.

Personality Assessment

The personality test results included measurements of higher than average (just above one

standard deviation of the norm group) on the Stress Scale. An individual with medium to high

stress levels may experience anxiety, the inability to relax, emotional tension, and physical

symptoms such as headaches. Ms. Black reported experiencing all of these symptoms. Her score

on the Procrastination Scale falls just below the average procrastination scale of the norm group,

which indicates that she tends to be organized and that she tends to complete work on time

without rushing, although not always.

Ms. Black scored in the severe range for both current (state) and overall (trait) anxiety on the

State-Trait Anxiety Inventory. On the Anxiety Test from anxietycentre.com, she also scored in
the severe range for anxiety. Her score on the Manifest Anxiety Scale was in the high score

range. These scores suggest that anxiety is a significant concern for her at this moment, although

it also seems to be a part of her general personality makeup. Ms. Black’s scores on the Beck

Depression Inventory and the Major Depression Inventory both suggest that she experiences

moderate symptoms of depression. Ms. Black displayed a high level of Neuroticism on the IPIP-

NEO Big Five Test, which indicates that she is easily upset, emotionally sensitive, and often self-

conscious, and this is consistent with her anxiety and depression scores on the other tests. The

IPEP-NEO Big Five Test also described Ms. Black as organized, achievement-striving, and

enjoying helping others. She also displayed a strong preference for introversion over

extraversion on both the IPIP-NEO Big Five Test and the Myers-Briggs Personality Profile,

indicating that she tends to restrict socialization, prefers solitary activities, and tends to be quiet

and reserved. The Myers-Briggs Personality Inventory also identified Ms. Black (with the 4-

Letter Code) as having a strong tendency to emphasize personal feelings and the feelings of

others when making decisions versus thinking logically and objectively, and having a strong

tendency to mentally live in the future over the present. In many areas, Ms. Black’s personality

was very consistent among these personality tests.

On the Achievement Anxiety Test, Ms. Black scored in the overall average range, indicating that

she has a normal amount of anxiety during academic testing situations compared to the norm

group.

On the Interpersonal Behavioral Inventory, overall, there were a few indicators with aggression

or hostility, but Ms. Black did score higher on a measure of Indirect Hostility. This indicates she

may have a high level of irritability.

Ms. Black scored in the intermediate range on the Locus of Control Scale, which suggests that

she believes she controls her fate in some areas but not in others. On the Eysenck Personality

Questionnaire – Extraversion items, she scored very below average compared to the norm group

of college students, which is consistent with her introversion scores on the other tests. On the

revised Cheek and Buss Shyness Scale, Ms. Black’s score indicated she was somewhat shy.

On the SCOFF Questionnaire, Ms. Black did not indicate that she currently has anorexia or that

she needs further testing for an anorexia diagnosis.

Ms. Black’s responses to the Incomplete Sentence Blanks were fairly revealing. She stated that

the happiest time in her childhood was “before my parents divorced.” She said that her father

“cares about me but is too controlling.” Something she wants to know is “how to manage my

anxiety.”

Diagnostic Impressions

Generalized Anxiety Disorder

Moderate Depression

History of Eating Disorder

Summary and Conclusions

Ms. Black is a first semester psychology freshman with a history of high academic achievement

in high school. She is currently doing well academically in her college courses. However, she has

been experiencing a much higher anxiety level since her transition to college. She has been

experiencing dominating anxious thoughts, more severe headaches, feelings of social isolation,
and the inability to relax. She feels her symptoms are interfering with her overall level of

happiness and fears they might begin to interfere with her ability to succeed in school.

When Ms. Black was a child, her parents divorced. She expressed that the divorce and its after-

effects were difficult for her to manage. She also has difficulty creating stable social

relationships. Ms. Black has a history with eating disorder symptoms, although she says they are

not currently prevalent to her. Ms. Black also has a history of mental health counseling, although

she did not follow through with all treatment plans.

Testing showed that Ms. Black has high intellectual ability and no evidence of learning

disorders. Combined with her academic history, she is likely to continue to succeed in her

college work.

Ms. Black is reporting a high degree of anxiety, stress, and symptoms of depression. This seems

to be leading to a lack of confidence needed to use supportive resources and to be able to manage

her symptoms on her own. She does appear highly motivated to overcome her symptoms so that

she can continue to succeed academically, improve her internal thought processes, and improve

socially. She has also avoided negative behaviors that could be distracting from progress.

Recommendations

1. Individual counseling to build coping strategies for managing anxiety and depression

symptoms

2. Stress management training

Madison A. Welsted, 11-07-2020