Assessment Report

Demographic Information
Name: Laura Smith DOB: 8-2-2001
Address: 4 Nutmeg Street, Wellsboro, PA 16901 Age: 19
Phone: (570) 555 - 1234 Gender: Female
Email: zuchowskieo20@mansfield.edu Ethnicity: White (non-Hispanic)
Date of Interview: 11/8/2020
Name of Interviewer: Emilie Zuchowski

Presenting Problem or Reason for Referral

Laura Smith is a 19-year-old white female of average height and heavier build. She was self-
referred for an assessment because of concerns of high stress levels, panic attacks, and anxiety
that impacts her ability to do her schoolwork. She has had difficulty over the past school
semester with procrastination and lack of motivation due to her anxiety levels. She has been
turning in late assignments, asking for extensions, and waiting until the day of or the day before
to do difficult assignments due to past panic attacks when she has tried to do her work. She has
been difficulty sleeping, including waking up several times throughout the night, nightmares, and
either sleeping too much or not at all. She is concerned that if she does not regain control and
find ways to manage her anxiety, she is going to fail. She is willing to do any tests or any
methods to get her grades back on track. An assessment was conducted to determine her
diagnosis and treatments avaliable.

Family Background
Ms. Smith was raised in Wellsboro, PA and is the oldest with only one younger brother. Her
younger brother is four years younger and is in high school. She reported that she had a good
relationship with her parents, and they have always been close. She also has a good relationship
with her brother, even though they are very different people. She always felt that she could
express her feelings with her parents, and they were very supportive of her.
Ms. Smith reported that she was very nervous to go to college and thought it would be very hard
to live in a new place since she had lived in one town her whole life. She attended a different
university for her first year and had trouble adjusting to college life. She felt overwhelmed by
coursework and very homesick. She only made a few friends and was very reserved at that
school. Problems with her parents started to arise due to her newfound independence and her
parents’ inability to accept Ms. Smith’s new phase in life. She felt that their relationship was
strained, and they were growing apart which was difficult her because they played an important
role in her life.
After having troubles her second semester, Ms. Smith transferred to Mansfield University and
moved back home to help cut down on tuition costs and because of her anxiety of living at
college. Ms. Smith stated their relationship is still not the same since she has since gotten a job
and is involved in a romantic relationship, so she is not able to spend much time with her family
as she used to. Her parents have had a hard time adjusting to her new lifestyle and she feels they
are not as close as they once were.

Significant Medical/Counseling History

Ms. Smith reported that she has had a history with mental health problems and has been to
counseling in the past. She was having mild depressive and anxiety symptoms in eighth grade
and saw a counselor regularly from eighth grade to nineth grade. She has constantly struggled
with depressive symptoms throughout high school and college. She also saw an on-campus
counselor her first semester at college to help cope with the transition and her resurfacing
depression. She was prescribed vitamin D by her doctor but was never on any kinds of
antidepressant or anxiety medication.

Substance Use and Abuse

Ms. Smith stated she has never tried any major illegal substances and has only consumed alcohol
during her second semester at college. She stopped consuming alcohol as frequently as she did
(almost every weekend) when she moved back home. She had tried marijuana a few times and
has been recommended by her peers to try medical marijuana to help with anxiety. She has been
open to it but has been deterred by the price.

Educational and Vocational History

Ms. Smith attended public school from kindergarten up to the time she graduated high school.
She did well in school and was always on the honor roll. She was quiet and reserved most of the
time, so she had no issues with any teachers or other staff members. She was not involved in
many activities and had a hard time making friends. She stated that some issues she had where
probably because of anxiety, but she did not understand what anxiety was at that age. Although
she had minor anxiety, she had a perfect attendance, so the anxiety was not too much to the point
of not being able to go.
Ms. Smith is in her second year/third semester of college as a psychology major. She was
originally a biomedical science major her first semester, but the classes where too demanding
and overwhelming for her. She switched to psychology her second semester but did not have
many psychology classes due to switching late. Her third semester is her first time being exposed
to psychology classes that interest her and she has reported that she is much happier in the
classes she is taking now. She stated that she chose psychology because she wants to help others
through counseling but working in a medical field or medical setting is too much for her. She
also stated that her grades have decreased significantly, and she does not do as well in college as
she did in high school. She has troubles figuring out how to study for tests and retaining
information for certain classes she has no interest in, such as history.
She has had a few minor places of employment. Her recent job has been her longest one and
most independent job. She works every summer for four to five weeks processing doe licenses at
the courthouse where her mom works at. She reported that the job is very laid back and enjoys it.
Her current job working at a department store is her second job she got on her own. The first one
was at a pizza place, but she only worked there for a month before she was fired. She reported
that her job caused her a lot of anxiety and fear for getting another job. She has been working at
her current job for about five months. She stated that the job can be stressful at times, but it is not
too overwhelming, and she felt that it has had a positive impact on her life.

Other Pertinent Information

Ms. Smith stated that her issues with self-esteem and body issues have also had an effect on her
anxiety. She is on the heavier side, so weight and self-image has been a persistent problem in her
life. She stated that her issue of self-esteem has held her back in many opportunities in her life.
She denied ever having any eating disorder symptoms.

Mental Status
Ms. Smith was dressed casually, well-groomed, and had good hygiene. She made appropriate
eye contact and was very reserved. She did not speak much and had a soft voice. Her body
gestures suggested an anxious mood. She had no issues with comprehensiveness or memory. Her
verbal communication was clear, and she appeared averagely intelligent. She denied any suicidal
thoughts, psychotic symptoms, or homicidal thoughts. Her main concerns were general anxiety
that interfered with her classes and relationships.

Test Results
The following tests were conducted: Stress Test, Procrastination Test, Interpersonal Behavioral
Scale (IBI), State-Trait Anxiety Inventory, Beck Depression Inventory, Myers Briggs Test, Big
Five Personality Test, Locus of Control, Manifest Anxiety Test, Shipley Institute for Living
Scale (SILS), IQ test at IQ.com, Emotional IQ test, and Incomplete Sentences Blank.
Cognitive Abilities
The first test used to evaluate cognitive abilities was the Shipley Institute of Living Scales
(SILS), which scores intellectual functioning through word patterns. There were two sections,
one evaluating verbal and reasoning. These were both totaled together to get her overall score.
She received a verbal T-score of 49, which is in the 45th percentile (meaning she did better than
45% of people who took the test) and that is equivalent to an dIQ score 98, which is in the
average range. She received a reasoning T-score of 42, which is in the 20th percentile, and that is
equivalent to an dIQ score of 90 which is in the average range. The combined score placed Ms.
Smith in the average range with an overall IQ of 95.
Ms. Smith’s IQ score from IQ.com was 113, which put her in the higher end of average range.
This core is slightly higher than her IQ score of 95 in the SILS test. This could be explained by
possibly a recording error or differences in the questions between the two tests. However, they
are both in the average range.
The Emotional IQ test was used to test her ability to identify and control her own emotions as
well as other. Since Ms. Smith scored in the average range with a score of 100, she is able to use
her emotions affectively to communicate, empathize, overcome challenges, and resolve conflict.
Overall, the tests done for cognitive abilities indicate that Ms. Smith has an average to higher
average level of intelligence. They do not indicate any learning difficulties that would impact her
ability to perform well in school.

Personality Assessment
The first test used to assess Ms. Smith’s personality was the Procrastination Scale. She scored a
57, which is a little higher than the norm group average (54.6). This indicates high
procrastination. People who have high procrastination tendencies have higher levels of
frustration, guilt, stress, and anxiety.
Ms. Smith scored a 69 for the Stress Test, which was also a little higher than the norm group
average (63.2). This indicates high stress. People with high stress levels could experience
physical symptoms, such as aches, insomnia, or headaches; or emotional symptoms, such as
depression/anxiety, lack of motivation, or irritability/anger. Because Ms. Smith scored high on
both her procrastination and stress tests, this could indicate a correlation between the two. High
procrastination may contribute to her stress and vise versa.
The Interpersonal Behavioral Inventory was used to measure her hostility levels. Ms. Smith’s
overall total was a 22, which is relatively low. The only high categories she had were resentment
and suspicion. The other five categories were low. Overall, there were a few indicators of
problems with aggression or hostility. Because of the higher score of resentment (5), it indicates
she might have tendencies to be jealous of others, often to a level of hatred. It is often a feeling
of anger at the world over real or imagined mistreatment. Because of the higher score of
suspicion, she might have tendencies to project hostility onto others. It can vary from being
distrustful and wary of others to serious beliefs that other people are planning harm on her.
The State-Trait Anxiety Inventory measured State and Trait anxiety. State anxiety measured how
Ms. Smith was feeling at the moment and trait anxiety measured how she felt in general. Both in
the state and trait anxiety, she scored mild anxiety. She scored higher for trait anxiety (36) than
state anxiety (45) at the time, so this indicates that she is an overall mildly anxious person, but
her state of anxiety ranges and she is not constantly anxious. This line up with her other anxiety
tests she took (the Manifest Anxiety test), which also indicated mild to high levels of anxiety.
This makes sense since she has high stress levels, and a symptom of high stress is high anxiety.
She stated that the two tests (STAI and the Stress Test) had similar questions.
The Beck Depression Inventory measured the range of depressive symptoms. Ms. Smith scored a
9. Her score indicated mild depression. However, her score was on the lower range. Symptoms
of mild depression include lack of motivation, loss of interest in activities, appetite changes, and
difficulties concentrating at work. Due to Ms. Smith’s past experiences with depression, she
stated this was anticipated.
The Myers-Briggs 4 Letter Code Test measured four different personality aspects. Ms. Smith’s
four-letter code was I (Introversion), S (Sensing), F (Feeling), and J (Judging). The results
reported she has a moderate preference of introversion over extraversion, a slight preference of
sensing over intuition, a moderate preference for feelings over thinking, and a slight preference
of judging over perceiving. People who prefer introversion draw energy from within themselves
and if there is too much attention spent in the outside world, they need to retreat to a private
setting to recharge. People who prefer sensing favor clear, tangible data that affect the direct
present. People who prefer feeling judgement make their decisions with a global, visceral,
harmony, and value-orientated way. They pay attention to the impact of decisions and actions on
other people. People who prefer judging lean towards organization and planning and want to
have order in the world in an assertive or light manner.
The Big Five Personality Test is similar to the Myers-Briggs test in which it measures five
different categories of personality traits. Ms. Smith’s extraversion score is low (7), indicating she
is introverted, reserved, and quiet. She indicated a strong tendency towards agreeableness. Her
score is 79. People with agreeableness traits have a strong interest in others’ needs and well-
being. They tend to be pleasant, sympathetic, and cooperative. She indicated a strong tendency
towards conscientiousness. Her score is 88. People with a high conscientiousness tend to set
clear goals and pursue them with determination. They are usually described as reliable and hard-
working. She indicated high for neuroticism. Her score is 79. People with high neuroticism tend
to easily get upset and are described by others as sensitive and emotional. Her score on openness
is low. Her score is 32. People with low openness think in plain and simple terms, are down-to-
earth, practical, and conservative. She consistently scored with low extraversion/high
introversion on this test and the Myers Briggs test. Her high score of neuroticism aligns with her
high/mild scores on her anxiety and stress tests. Her high consciousness tendency was also
consistent with her high procrastination score.
For the Locus of Control test, Ms. Smith’s score is a 16, which indicates she has a fairly strong
belief that events are beyond her control. She may not feel that there is much of a connection
between her behavior and her outcomes. She might be relatively less likely than others to take
credit for her successes or to take the blame for her failures. She might tend to believe that
success and failure are primarily a matter of luck and chance breaks.
There was an additional anxiety test called the Manifest Anxiety Test. Her score is a 26, which is
a high anxiety range. This test measures behavior and emotions. This test aligns with her other
anxiety test she took and her stress and procrastination tests because they were also high/mild.
For the Incomplete Sentences Blank, Ms. Smith had to fill in the rest of a group of sentences.
Some of these were revealing. In response to the stem “my nerves”, she responded “are high.”
She also responded to the stem “I suffer” with “with anxiety.” These aligned with her anxiety
tests she took because they showed mild anxiety and the sentences confirmed that her mental
state was anxious with many negative sentences about anxiety or being worried. One positive
response she had to “the best” was “thing in life is friends.”
Overall, many of these personality tests indicated high stress levels, high anxiety levels, and high
procrastination levels. These all correlate together because one usually affects the other. These
also revealed that she has a very introverted and reserved personality, and she is a clear and
organized thinker. She tends to think pessimistically, and she is a goal driven person.

Diagnostic Impressions
Generalized Anxiety Disorder
Mild Depression

Summary and Conclusions

Ms. Smith is a third semester sophomore who arrived at her current university after transferring
from her last due to anxiety and financial concerns. Her first year of college was very anxiety
filled, overwhelming, and socially difficult. Her current semester she is concerned about
procrastination and lack of motivation due to increased anxiety. In her past she had diagnosed
mental health concerns and counseling experience that seem to resurface with increased levels of
stress.
Ms. Smith’s test results concluded that she has an average level of intelligence that concludes to
no indications of any learning disorders that would inhibit her to do her college schoolwork. She
may lack stress management skills that impact her anxiety and procrastination levels and explain
her physical and emotional symptoms and decreasing grades. Many of these things
(procrastination, anxiety, lack of motivation, depression, etc.) all relate to one another, so many
of these factors could be at play in explaining her sudden drop in grades. She is interested and
eager to make changes to be able to do well in her classes. Although she is reserved and timid,
she is a determined and goal-orientated individual with all the necessary capabilities to be
successful in school and in her personal life.

Recommendations
1. Schedule counseling appointments to help build stress management techniques
2. Incorporate numerous daily activities to decrease anxiety, such as positive thinking,
relaxation techniques, exercise, a healthy diet, and a consistent sleeping schedule
3. Build a strong support system with trusted people for daily and personal stress outlets

Emilie Zuchowski