Psychological Evaluation Instructions

The psychological evaluation report will consist of the following sections: Identifying
Information, Reason for Referral, Background Information, Behavioral
Observation, Assessment Results and Interpretation, Summary, Recommendations,
and Signature. The identifying information will be reported in the same outline format
as you used for the biopsychosocialspiritual interview. However, please list the current
date of the report where the interview date was previously listed. In addition, you will list
the assessments and the administration dates. The listing of tests (assessments) will come
immediately after the identifying information. Please include the
biopsychosocialspiritual interview in this list. Write the full title of the test and list the
abbreviation of the test in parentheses. You may use the abbreviated name in the body of
the report. For example:

Psychological Evaluation

Identifying Information

Ima Counselor (substitute your name) Age: 31 years, 4 months

123 Happy Lane, Dallas, TX, 76010 DOB: 01/16/81

Home phone: 972-123-4567 Female

Occupation: Student Married

Evaluator: (your name) Date of Report: 12-7-12

Counseling Student

Tests Administered:

Biopsychosocialspiritual Interview (date)

Beck Depression Inventory-2 (BDI-2) (date)
Substance Abuse Subtle Screening Inventory (SASSI) (date)
General Ability Measure for Adults (GAMA) (date)
Taylor-Johnson Temperament Analysis (T-JTA) (date)
NEO Personality Inventory-3 (NEO-PI-3) (date)
Minnesota Multiphasic Personality Inventory-2 (MMPI-2) (date)

Reason for Referral

Ima Counselor consented to be evaluated so that (your name) could complete the
requirements for the course COUN 5315.

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Background Information

You will notice that the organization is slightly different for the psychological evaluation
than the biopsychosocialspiritual (BPSS) history. For example, “The Purpose of
Counseling” is equivalent to “Reason for Referral.” The remainder of the BPSS
evaluation will be listed under the heading of “Background Information.”
Do not use the headings from the BPSS write-up in the background section, but please
follow the same order when reporting the information. The format for the headings in this
report will be boldface and justified on the left margin (APA heading style). The report
will be single spaced in block paragraph form (double spaced between paragraphs) with
the exception of the identifying information. This is the format that will be followed for
this class. There is not a standard format across agencies.

Behavioral Observation

Include a statement concerning validity. For example: The results of the evaluation are
believed to be a valid assessment of Ima’s current intellectual and emotional function. If
for some reason you do not believe this is a valid assessment, explain why. Included in
the behavioral observation will usually be information regarding the examinee’s attitude
and approach toward the various tests. Example: Ima appeared relaxed and enthusiastic
about the assessment. However, when answering math problems, she commented that she
is not good at math.

Comments that would clarify the results would be included in this section. For example: a
comment could be included about the person feeling rushed, or he or she had difficulty
concentrating due to being tired.

Assessment Results and Interpretation

This section is the most important part of the report. The first paragraph will summarize
the results from the BDI. The next paragraph will summarize the SASSI results. The
following paragraph will summarize intelligence based on the GAMA results and the
remaining paragraphs will describe personality functioning based on the T-JTA, NEO-PI-
3, and MMPI 2 results.

Begin by reporting the results of the BDI-2. For the BDI-2 write-up, the first sentence
will include the examinee’s name, score, the instrument used, and the client’s
classification according to his or her score (0-13 minimal, 14-19 mild, 20-28 moderate
and 29-63 severe). The wording in the example below may be used, substituting your
examinee’s information. The next sentence will include a summary of the symptoms that
the client reported. The number of sentences needed to adequately describe the individual
will depend on the number of symptoms reported. Do not simply list the symptoms, but
group them in a way that will be useful to someone reading the report. For example, if
several of the symptoms describe the person’s cognitive functioning, group those
symptoms together. Symptoms may also be grouped according to emotional, behavioral
or interpersonal symptoms.

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Examples: Ima Counselor obtained a score of 2 on the BDI indicating that she is
experiencing minimal symptoms of depression. She reported that she is feeling more
restless and having more difficulty concentrating than usual. Or: Ima Counselor obtained
a 0 on the BDI indicating that she is not experiencing any symptoms of depression.

Below is an example of the first two sentences to be included in the SASSI write-up:

Ima Counselor’s scores on the SASSI indicate that she has a low probability of having a
substance dependence disorder. Approximately 92% of people whose scores are similar
to Ima’s are found not to have a substance dependence disorder.

If the examinee’s scores fall in the in high probability group, there is a 92% probability of
substance dependence. After reporting the probability of substance dependence, include
a statement reporting any indication (or not) of acting out, defensiveness, and emotional
pain. This information is under SASSI “Screening Results Overview.” If there is an
indication of Random Responding, this will be reported under the behavioral observation
section.

Information to include on the GAMA: the IQ score, confidence interval, ability

classification and percentile. For example: On the Gama, Ima obtained an IQ score of 94
placing her level of functioning in the average range. Her percentile score of 36 indicated
that she performed equal to or better than 36% of the people her age who have taken the
Gama. At the 90 % confidence level, Ima’s true IQ score will fall between 87 and 101.
(Notice that in communicating the confidence interval (87 to 101), the confidence level
(90%) is also reported.) Another way to communicate confidence level is to say “90 %
of the time Ima’s score will fall between 87 and 101.”

Next, describe the person’s relative strength or weaknesses on the four subtests using the
descriptive categories. If there were no significant differences between subtests, state
that. Example: None of subtest scores was significantly higher or lower than her overall
average score. The exact wording from the result section of the profile report may be
used for this.

The next paragraph will include a description of the results for the T-JTA. The handout
that has Chuck’s self-report is an example of how the T-JTA should be reported. Please
list the scales in parentheses. Example: Ima obtained three scores in the “excellent” range
(Active-Social/Quiet, Expressive-Responsive/Inhibited, and Sympathetic/Indifferent).
These scores suggest … interpret the scores by looking at the list of traits and opposites
under the profile. Describe all scores including the improvement needed scores. If there
are improvement needed scores, remove the statement recommending counseling from
this section and instead make the recommendation in the recommendation section.

After the T-JTA you will report on the NEO-PI-3. Before writing the paragraph about
the individual, make a chart reporting the domain scores. Here is an example:

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Scale T Score Range

Neuroticism 53 Average

Extraversion 44 Low

Openness 56 High

Agreeableness 50 Average

Conscientiousness 50 Average

In the first paragraph write a sentence or two describing the individual on each domain.
Basically, do two things: 1. Verbally describe the chart 2. Give a brief description of what
the domain score means. For example: Ima Counselor obtained a T score of 53 placing
her in the average range on Neuroticism. In general, she is able to deal with the stresses
of life but may occasionally experience feelings of guilt, anger or sadness. Follow this
format to describe the remaining 4 domains.

Include a discussion of all the high and low facet scores. This may be done in one
additional paragraph or several paragraphs depending on how many facets are being
described. A score is high if the T score is above 55 and it is considered low if the T
score is below 45. Think about how these unique pieces of information help you
understand the person. Look across domains and consider how facet scores in other
domains may influence each other.

Describe each facet score that is very high, high, low, or very low. The goal is to
synthesize the information so that the reader will have a better understanding of the
individual. For the purpose of this class, after making a statement about the individual,
justify the statement in parenthesis. Ima appears to enjoy interacting with people (E2-
T=70).

The last instrument to discuss is the MMPI-2. State information about “profile validity”
under the behavioral observation section of this report. Treatment considerations will be
listed under the recommendation section of this report. The profile frequency does not
need to be summarized, but moderate, high and very high scores for all clinical scales and
low scores of 5 or 0 should be included. This information will be found in the
symptomatic patterns and interpersonal sections of the MMPI report. I have also copied
several pages from the manual that will help you in interpretation. You will not use all
the descriptors from the tables or the MMPI-II report, but only those that apply. In other
words, use your clinical judgment based on other information that you have gathered. Put
the scale number in parentheses after your statement.

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Summary

The summary should include all pertinent information. At times, this is the only section
that is read. There should not be any new information in this section. In the remaining
paragraphs, do not include scores or talk about scales. Those who would understand the
scores will usually have access to the individual profiles. The scores are usually
meaningless to other people, such as the client or parents. The written interpretation of
the results and the description of the individual will help the reader better understand how
the client functions.

However, for the purpose of this class, after making a statement about the individual,
justify the statement in parentheses. Ima appears to enjoy interacting with people (E2-
T=70). Remember that each instrument measures a slightly different aspect of
personality. At times the scores will simply confirm other results, but the scores may
also provide additional information. Because of the numerous personality profiles that
could be generated, it is difficult to offer a suggested outline for the paragraphs.

However, in describing a person, information regarding the person’s emotional state,

ability to deal with frustration, interpersonal style and ability to be productive are
included. In determining the outline, it may be helpful to begin by listing on a separate
piece of paper all the information from the various instruments that will be included in
the summary. Go back over the list to identify themes that will help organize the
material. This will help in synthesizing the information. Do not organize the
paragraphs by simply summarizing the information from one instrument in a
paragraph, and then summarizing information from the next instrument in the next
paragraph.

Communication of Results

After careful consideration, synthesis, and analysis of the data collected from the BPSSH,
intake interview, and assessments, describe the manner in which assessment results and
your overall evaluation of the client should be communicated. Include possible verbiage
to be used, anticipation of client reaction and how this would be addressed and discuss
the importance of communicating assessment results as an integral component of the
overall therapeutic relationship.

Recommendations

This section should come from careful analysis of the data collected during the interview
and test results. Look in the reports for suggested recommendations, but also use your
counseling skills. If this person was in your office, what would you recommend?
Conclude the report with a signature line. Under the line type your name and list
yourself as a counseling student (Example: Ima Counselor, Counseling Student). Be sure
to sign the report.

Turn in your biopsychosocialspiritual history and the actual test data/results when
you hand in the psychological evaluation report. Please put all the material in a
manila envelope (with a clasp) with your name on the envelope.