WRITING UP THE RESULTS OF INTERVIEW AND PSYCHOLOGICAL TESTS:

OBJECTIVES:
1. Thoroughness: Enough to document the basis for a diagnosis and treatment plan.
2. Time-efficiency: It does not require too much time that it would be unfeasible for a busy clinician to
produce.
3. Readability: It is not lengthy to provide sighs from equally busy colleagues who must read the writeup because of their involvement in the clients treatment
OUTLINE FOR PSYCHOLOGICAL EVALUATION
Identifying Data:
Date of Report:
Name of Examiner:
Referred by:
I.
II.
III.
IV.
V.
VI.
VII.

Chief Complaint/ Reason for referral/ Referral Question

Evaluation Procedures
Behavioral Observation
Background Information (relevant history)
Test Results
Impressions and Interpretations
Summary and Recommendations

IDENTIFYING DATA:
Name:
Age (date of birth)
Sex:
Civil status:
Occupation:
Possible reasons for Referral
Intellectual evaluation: routine, intellectually disabled, gifted.
Differential diagnosis, such as the relative presence of psychological difficulties versus organic
impairment.
Assessment of the nature and extent of brain damage.
Evaluation as a component of, and to provide recommendations for, career/vocational counseling.
Personal insights regarding difficulties with interpersonal relationships.
Evaluation of appropriateness for psychotherapy.
Evaluation as an aid in client placement.
EVALUATION PROCEDURES
List of tests and other evaluation procedures
Full test names are included along with their abbreviations.

Includes the date on which different tests were administered and the length of time required to
complete each one.
Includes review of relevant records such as medical records, nursing notes, police records, previous
psychological or psychiatric reports, or educational records.
BEHAVIORAL OBSERVATIONS
It can provide insights into his/her problem and may be a significant source of data to confirm,
modify, or question the test-related interpretations.
Observations can be related to a clients appearance, general behavioral observations, or examinerclient interaction. It has to be specific.
A description of the clients physical appearance should focus on any unusual features relating to
facial expressions, clothes, blood type, mannerisms, and movements.
The behaviors the client expresses toward the test material and the examiner often provide a
significant source of information.
Behavioral observations should be kept concise, specific, and relevant.
The focus should be on clients behaviors that create a unique impression.
Summary of information from a Mental Status Examination
At the end of the Behavioral Observations section, it is appropriate to include a statement indicating
the validity of the assessment procedures.
Given the consistency and details of the clients responses, the clients high level of motivation and validity
indicators on the tests, the assessment appears to be an accurate measure of the clients current level of
functioning.
BACKGROUND INFORMATION (REVEVANT HISTORY)

CLIENTS General Background

Family Background
Personal History
Medical History
History of the Problem
Current Life Situation

TEST RESULTS:

Mode of presentation: Include standard/sten/stanine/T scores or percentile rank (rather than raw
scores) and relative magnitude of the relevant scores
Intelligence test score: include IQ scores (verbal, performance, full scale IQ for WAIS

INTERPRETATIONS
Cognitive functioning

It includes a general estimate of the persons intelligence and discussion of more specific abilities:
memory, problem solving, abstract reasoning, concentration, and fund of information

/Discusses the clients intellectual strengths and weaknesses

Emotional/Intrapersonal Functioning and Interpersonal Relationships

It should be based on referral questions

Organize topics based on the context of the report and the needs of the referral source and client.

Level of Psychopathology
SUMMARY AND RECOMMENDATIONS
Summary

Restate succinctly the primary findings and conclusions

Select only the most important issues and not the overwhelm readers with needless details.

Recommendations

Steps to be taken to solve problem

It should be clear, practical, obtainable, and should relate directly to the purpose of the report.
Prerequisites: clinician must understand the problem, the best alternatives for remediation, and the
resources available in the community.
It must answer the referral question and have decisional value.
Steps to be taken the problem
It should be clear, practical, obtainable, and should relate directly to the purpose of the report.
Prerequisites: clinician must understand the problem, the best alternatives for remediation, and the
resources available in the community.
It must answer the referral question and have decisional value.
Different levels of decisions:
Setting or context: outpatient, day hospital, inpatient, new work environment, change in schools.
Developing a relationship with the client: degree of resistance, level of insights, interpersonal style,
and empathy.
Specific intervention procedures: systematic desensitization, stress management, emotional support,
vocational training, rehabilitation, special education.