****ATTACHED IS THE CLIENT CASE SUMMARY****
—— MR. JEREMIAH SMITH ——
For this assessment report you will be taking on the role of a clinician who is conducting an assessment and providing treatment recommendations for the client provided. You must use the information provided in case history and identify the most salient information that belongs in each section. Do not simply copy and paste the information provided. You must make a professional judgment about which information is the most important information to include in the psychological report and where to include that information in your report. Your assessment report must follow the format below and it must include each of the sections and their headings listed below:
I. Identifying Information
Within this section, you will record basic information on your client including the persons name, sex, gender, ethnicity, sexual orientation, age, handedness, and occupation or grade level. For the purposes of this assignment, you are free to create any relevant demographic information that is not explicitly stated in the case scenario. All information you create must be consistent with the information provided and any conclusions you draw in subsequent sections of your paper.
II. Reason for Referral
Within this section describe the referral source and the purpose of the assessment. The information you provide in this section must justify the decision to conduct a formal psychological assessment based and must model ethically and professionally responsible assessment practices.
III. Current Symptoms/Presenting Concerns
The information in this section of the report would typically come from an interview with the client and family (if applicable, e.g., if the client is a child or person with suspected dementia). You must use the information provided in case history to identify the most salient information that belongs in this section. Choose information to include in this section based on the consistency with the reason for referral and purpose for testing. Here is where you will apply your methodological and theoretical assessment formulations of the client that will justify the decision to conduct a psychological evaluation on this client.
IV. Psychosocial History (complete each of the sections below based on the information in the case you selected)
Educational history
Occupational history
Medical history (including substance use/abuse)
Psychiatric history
Social history
V. Interpretation of the Results
In this section explain your interpretation of the results in the data table provided for the case you selected. Utilize the information available and create appropriate subheadings to organize the results. For example, if your data table contains information on intelligence and achievement, then you should create appropriate subheadings to organize your findings in this section of the report. Create a sufficient number of subheadings to allow you to provide interpretations for all assessment instruments administered. If you have more than one measure of a particular psychological construct (e.g., personality and emotional functioning), present your interpretations of all measures that apply to that construct under the same subheading.
VI. Diagnostic Impressions
Based on the history provided and interpretation of test results, use the DSM-5 to provide a diagnosis (or diagnoses) for the client in a manner that demonstrates the ethical and professional use of assessment results. You must justify your diagnostic conclusions based on your knowledge of the validity and reliability of the assessment instruments. If there are multiple potential diagnoses to consider, then these must be explained and justified as well. Also include information about alternative diagnoses and why these were not chosen.
VII. Recommendations
Within this section, provide treatment recommendations for the client based on the diagnosis and information about the clients current living situation. Develop recommendations that are evidence-based and include peer-reviewed articles that support your choice(s).
