Psychological Assessment Report 1

Demographics

Name: M

Father name: A

Age: 21

• Identifying Information

Client 21 years old, unmarried, male. He is first born and has two younger brothers. He lives in a joint
family system with his parents. He belongs to an average socio-economic class.

• Source and Presenting Complaints

Client was referred by medical specialist. her presenting Complains were depressed mood, weight loss
suicidal thoughts and mood changes from two weeks he also reported that he over thinks and worry

about things and has started crying a lot. All day he stays alone at home.

• Interviewed Information

Client started school at the age 6 and reported no difficulty in social interaction with peer group No

academic problems were reported. she reported he used to score good grades. she reported mixed

symptoms of anxiety and depression with a lot of sadness. She reported that she can not focus or

concentrate and faces decreased insomnia at night. She doesn’t like meeting people or going out.

• Psychological Assessment

* Informal Assessment

The informal assessment can be through:

* Clinical interview

* Mental Status Examination

Clinical Interview

Interview was conducted to identify Client problem, history of present illness, background history,

personal history, occupational history and educational history. The client was cooperative and compliant

during the interview.

Mental Status Examination

The Client appearance was normal when he entered the session room. He was sitting in comfortable
posture. His hygiene was satisfactory. His speech was normal in rate. His voice tone was normal. His talk
was relevant. He maintained good eye contact. His physical built was good. His mood was euthymic and

he had answered the question clearly. His level of consciousness was alert. He was very attentive and

also concentrates on the questions which the therapist asked to him. He had no impairment in memory.

His general knowledge was normal. He reported insight regarding his problem and he wanted to get to

normal life. He has no delusions. He has no obsessional thoughts. The rapport was built so easily and the

therapist finds no difficulty in establishing and maintaining it.

Formal assessment

1. BDI - Beck depressive inventory

2. BAI – Beck anxiety inventory
3. HTP House Tree Person
4. BGT Bender Gestalt Test
5. SPM- standard progressive matrices

• Behavior during Testing session

Client was cooperative, 4 sessions have been taken including initial intake. he was not much talkative he

was very relaxed through tests sessions. he was cooperative and motivated to perform on Psychological

tests and followed the instructions carefully.

• Tentative Diagnosis

Major Depressive Disorder.

• Prognosis

Client prognosis is favorable because he was cooperative, attentive and show interest in reporting

problem during interview.

• Recommendations

1. sleep management

2. Psycho pharmacology

3. individual counselling

4. Psycho education