Assignment: Psychological Assessment Report

Assignment: Psychological Assessment Report

Assignment: Psychological Assessment Report

Psychological assessment reports are written by psychology professionals who work in a variety of settings. In addition, professionals in many different subfields within psychology, education and health must be able to read, understand and apply information provided in psychological assessment reports in order to effectively serve their clients. For your Final Assignment, you will demonstrate your knowledge of psychological assessment by applying the information you have learned throughout this course in the interpretation and write up of a psychological assessment report.   Your Final Project will be based on one of the case information/data tables that have been provided in the course.  The three cases consist of one adolescent assessment, one adult assessment, and one geriatric assessment.  It is expected that your Week Five final project case will be the same case that you selected in Week Two and that you incorporate feedback provided to you by your instructor on the Week Two assignment when developing your final project. To complete this assignment, you will choose the client from the list below which you chose for your Week Two assignment. Assignment: Psychological Assessment Report


Timothy Childers (Adolescent Male)

Mr. Kyle Jones (Adult Male Personal Injury Case)

Mr. Jeremiah Smith (Geriatric Male Case)

As you write up your assessment report you will be taking on the role of a clinician who is conducting an assessment and providing treatment recommendations for the client that you choose from the list 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 person’s 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. Assignment: Psychological Assessment Report

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. Assignment: Psychological Assessment Report

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 client’s current living situation.  Develop recommendations that are evidence-based and include peer-reviewed articles that support your choice(s).

The Assignment:

  • Must be 5 to 7 single-spaced pages in length (not including title and reference pages).
  • Must include a separate title page with the following:
    • Title of assignment
    • Student’s name
    • Course name and number
    • Instructor’s name
    • Date submitted
  • Must use at least 5 scholarly sources, including a minimum of 2 peer-reviewed articles published in the last 10 years from the Ashford University Library.
  • Must document all sources in APA style as outlined in the Ashford Writing Center.
  • Must include a separate title page and reference page that is formatted according to APA style as outlined in the Ashford Writing Center. (Links to an external site.)Links to an external site.
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    Client History Report

    Jovanka Perez

    ABS 300- Psychological Assessment (FAC1743A)

    Dr. Kathryn Morris

    November 6, 2017


    I. Identifying information

    Name: Kyle Jones

    Gender: male

    Age: 45 years

    Status: married with two children

    Nationality: Italian American

    Religion: Christian (Roman Catholic)

    Occupation: college professor

    Education level: PhD

    II. Reason for Referral

    Mr. Kyle was referred by his neurologist for a neuropsychological evaluation of changes in thinking following a motor vehicle accident that happened on March 12th 2009. During the instantaneous period following the accident, Mr. Kyle reported that he had been fine but only had unclear memories of the incidences later the accident. He later attended a game that he has no memory of and he had become quitter and less socially interactive according to his wife’s observations. Remarkably, his brain and spine evaluations at the Emergency Department showed no signs of spinal cord or focal brain injury. This was not the first time that Mr. Kyle was exposed to possible brain injury as he had been involved in a fatal accident while he was a teenager, not forgetting that he had been exposed to a fall on a cement floor when he was a child. The fall led to a brief loss of consciousness. Mr. Kyle reports that he experiences seasonal depression that lasts 3 to 6 months, with the last episode being caused by a memory of the motor vehicle accident in his teenage years. His condition seems to be deteriorating, despite the reported improvement a week after the accident. Assignment: Psychological Assessment Report

    III. Current Symptoms/Presenting Concerns

    Mr. Kyle reports unclear memories for the period following the motor vehicle accident alongside being amnestic about a soccer game he attended later. His wife observed that he became quitter and related less with people and he “was not making logical decisions”. He reports that the accident exposed him to problems like “fuzzy thinking”, reduced attention length, disorganization, losing track of tasks and/or thoughts, and condensed ability to plan and generate new ideas (e.g., writing lectures). One of the major symptoms reported by Mr. Kyle are memory loss characterized by problems during creation of lectures, losing his train of thought while teaching and forgetting applications that he has read. Also, he reports reduced coordination between his legs and hands. Other symptoms reported are headaches, neck pain, sleep disturbance and reduced appetite.

    While some of these symptoms and family history would point towards a neurological disorder, (Huang, Yu, Wu, & Tang, 2014) report that hereditary neurological disorders are more predominant in children than adults. Mr. Kyle himself had no history of any neurological disorder, except for episodic depression that most likely started during his childhood but diagnosed in adulthood. It is unlikely, therefore that he was suffering from an inherited neurological disorder given the condition of his maternal aunt.

    Another argument would be that Mr. Kyle had Post-Traumatic Stress Disorder (PTSD), especially judging from Mr. Kyle’s most recent depression episode that was caused by meeting the friends who were with him in the fatal car accident during his teenage years. However, according to (Beck & Coffey, 2007), following a fatal motor vehicle accident, PTSD is associated with phobias and fears such as driving or being in a car (Beck & Coffey, 2007)—Mr. Kyle denies having any fears of such kind. Moreover, PTSD is associated with substance abuse such as smoking and alcohol consumption (Beck & Coffey, 2007)—Mr. Kyle denies ever having a history of drug abuse and only takes a glass of wine to unwind. Finally, had he been suffering from PTSD, it is most likely that the individual psychotherapy and medication for many years would have brought it under control.

    Also, one would argue that Mr. Kyle, being vulnerable to cancer as seen in his family history, would be having a brain tumor (American Cancer Association, 2017). However, the diagnosis on his spine and brain immediately after the accident did not reveal any tumors in his brain. Assignment: Psychological Assessment Report

    Given these arguments, is would be justifiable to launch an assessment for Traumatic Brain injury for Mr. Kyle. According to (Huang, Yu, Wu, & Tang, 2014), symptoms of Traumatic Brain Injury include memory loss, difficulty in concentrating, strained thinking and understanding, difficulty in creating new memories, anxiety, loss of appetite, nausea, headaches, and loss of balance or coordination. Moreover, clinical examinations for Traumatic Brain Injury, just like the case of Mr. Kyle, result to normality.

    IV. Psychosocial History

    Educational History: no learning disabilities, performed well academically throughout school, has a Ph.D. in English.

    Occupational History: has been working fulltime as a college professor for the last 30 years; works a member of the institutional review board.

    Medical History: significant for hypercholesterolemia, hit a cement floor on his head when he was a child and lost his consciousness temporarily. Has a history of episodic depressions lasting between 3-6 months but not yearly but no history of drug or substance abuse.

    Psychiatric History: participated in psychotherapy for many years and was assigned a psychiatrist in case he needed medication.

    Social History: lives with his wife and two children, engages in activities such as driving and household chores, works regularly, plays golf with his friends, attends church with his family and has a good relationship with his daughter. Assignment: Psychological Assessment Report



    American Cancer Association. (2017, April 19). Family Cancer Syndromes. Retrieved from

    Beck, G. J., & Coffey, S. F. (2007). Assessment and treatment of posttraumatic stress disorder after a motor vehicle collision: Empirical findings and clinical observations. Professional Psychology: Research and Practice, 38(6), 169.

    Bogale, M. A., Yu, H., & Sarkodie-Gyan, T. (2013). Case study on assessment of mild traumatic brain injury using granular computing. Engineering, 4(10), 11.

    Huang, Y., Yu, S., Wu, Z., & Tang, B. (2014). Genetics of hereditary neurological disorders in children. Translational pediatrics 3, no. 2, 108.

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    JONES, Kyle Page 1 of 4


    About Mr. Kyle Jones

    Mr. Jones is a 45-year-old, right handed, male who was referred by his neurologist for a neuropsychological evaluation of changes in thinking following a motor vehicle accident (MVA) on 12/3/2009. He self-identified as being: Italian American (2nd generation). He reported “Roman Catholicism” as his religion. He has an earned doctorate in English and teaches at a private, Catholic university. He is reportedly a very popular instructor—well- liked by his students and colleagues. He has won faculty awards several years for teaching and mentoring students. Information provided by Mr. Jones: Mr. Jones reported he was the restrained driver of an automobile that was rear-ended while stopped at a light. He denied any loss of consciousness at the time of the accident, but reported only vague memories for the events immediately following the accident. He stated he was able to drive his car home after the accident and later attended a soccer game, but has no memory of the game. He reported his wife noticed he was much quieter and less socially interactive during the game and that he “was not making logical decisions”. He went to the emergency department (ED) the following day and was evaluated there for possible spinal and/or brain injuries. Medical records from this evaluation were not available, but according to Mr. Jones he was released the same day and imaging evidence did not reveal evidence of a focal brain or spinal cord injury. Mr. Jones mentioned that he was also involved in an automobile accident when he was a teenager. He said he was a passenger in the backseat and was “cruising” with some of high school friends. He said none of them were wearing a seatbelt. The car was rear-ended and the driver was thrown out of the car and killed. Since then, he as always worn a seat belt. He stated that he has no fears of driving or being in a car. Although he reported that his initial cognitive symptoms did improve over the week following the accident, Mr. Jones continues to report ongoing difficulties consisting of “fuzzy thinking”, reduced attention span, disorganization, losing track of tasks and/or thoughts, and reduced ability to plan and generate new ideas (e.g., writing lectures). He also reported occasional episodes of memory loss for previous events (e.g., does not recall talking to a student after class one day). Since the accident, people have told him he is more withdrawn and he was recently given feedback by president that he needs to become more “engaged”. He also reported reduced coordination when walking and when using his hands to pick up items. He stated he has been experiencing headaches several times per day and recently started physical therapy for treatment of head and neck pain. Mr. Jones stated he recently retained an attorney to assist him in dealing with the insurance company settlement for the above-referenced MVA. Medical history is significant for hypercholesterolemia. He reported being dropped on his head on a cement floor as a child with a brief loss of consciousness, but he denied any cognitive or behavioral sequelae. No other neurological history was reported. Mr. Jones stated he has a history of depression that in retrospect may have started in childhood, although he was not formally diagnosed until he was an adult. He denied every being depressed enough to consider suicide. He said his periods of depression tend to last about 3-6 months but that he does not get depressed every year. The last time he was



    JONES, Kyle Page 2 of 4


    depressed occurred when he went to his high school reunion and he saw the surviving friends who had been in the car when the driver was killed. He has participated in individual psychotherapy on and off for many years and is followed by a psychiatrist for medication management as needed. He described his current mood as stable and non- depressed, although neurovegetative symptoms of reduced appetite and sleep disturbance were reported. He denied a history of regular or heavy alcohol use, tobacco use, or recreational drug use. He stated he likes to unwind at the end of the day with a glass of wine. Mr. Jones reported a normal birth and development, and reached all milestones on time. He has never been diagnosed with any type of learning disability and did well academically throughout school. He completed college and his Ph.D. in English and has been college professor for the past 30 years. He continues to work full-time. In addition to his other responsibilities, he is a member of the institutional review board and reviews approximately 20 grant applications per month. Difficulties with occupational duties since the accident include problems creating new lectures, losing track of his train of thought while lecturing, and difficulty remembering applications he has read. There is family history of neurological disorder—a maternal aunt. His mother died at age 41 of cancer, and his father is living, age 67, and in good health. Mr. Jones has 4 siblings (2 full-sisters, 1 full-brother, and 1 half-brother by his father’s 2nd wife). He is the eldest of the children in his family. His full brother died of colon cancer last year and the younger of his two sisters has a diagnosis of thyroid cancer, but the remaining siblings are in good health. He has 2 children, ages 12 (daughter), and 15 (son), no health difficulties reported. His children are reportedly good students and he has no concerns related to their academic, social or emotional functioning. His daughter and son are both A-students. His daughter said she wants to be a pilot and his son told him he wants to be a dentist. Mr. Jones is married and lives in a house with his wife (age 30) and their children. He remains independent in activities of daily living, including managing finances, driving, and taking care of household chores. He enjoys woodworking in his spare time and also works out on a regular basis (3 to 5 times per week). He plays golf with several of his male friends. He attends church with his wife, their children and his father. Several other members of the extended family attend the same church. His hobbies include fishing and “tinkering on old cars.” He said that he likes to rebuild motors. He reported being proud of having many publications, including 3 volumes of poetry, but that he was even more proud of rebuilding the engine of a 1945 Chevy truck. He said his favorite color is blue and that his daughter bought him a purple shirt for Father’s day. When he looked stunned (he normally wears more conservative colors), his daughter said, “Purple is made of red and blue. You love blue. You love me. You will love this shirt.” He laughed aloud as he told the interviewer this story and said he wears the shirt proudly. His colleagues were initially stunned to see him wear a purple shirt to work. After he told them what his daughter said, whenever they see him in the shirt, someone comments, “Love your blue shirt.” Behavioral Observations: Mr. Jones arrived on time for his appointment. He attend the appointment alone. He was neatly groomed and dressed and ambulated/walked, stood, and sat independently without problems. His social skills were appropriate and he was fully cooperative throughout the evaluation. His emotional affect varied logically with the



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    topic being discussed. His energy level appeared a bit low. He did become more animated when he spoke of meeting his wife for the first time and when he spoke of teaching at the university. He appeared motivated to do well and to put forth good effort on testing. His scores on measures of effort were as follows: TOMM: Trial 1 = 49/50, Trial 2 = 50/50, Retention Trial = 50/50; CVLT-II forced choice recognition = 16/16; and are within the normal range. No overt behavioral indications of depression or other mood disturbance were observed and a full range of affect was demonstrated. Tests Administered: Review of records; Clinical Interview; Effort: Test of Memory Malingering (TOMM); General Cognitive Assessment: Wechsler Adult Intelligence Scale- IV; Attention Tests: Digit Span, Semantic Fluency, Lexical Fluency, Trail Making Tests, Paced Auditory Serial Addition Test (PASAT); Language Tests: Vocabulary, Boston Naming Test; Visuospatial Tests: Block Design, Target Cancellation; Learning/Memory Tests: California Verbal Learning Test-II (CVLT-II), Wechsler Memory Scale-IV (selected subtests); Reasoning/Abstraction: Wisconsin Card Sorting Test (WCST), Similarities, Matrix Reasoning; Mood/Affect: Beck Depression Inventory-II; Personality: Minnesota Multiphasic Personality Inventory-2 (MMPI-2) TESTING SUMMARY: Assignment: Psychological Assessment Report

    Raw Scores

    Normative Data

    Current Level*


    Full Scale IQ — SS = 118 High Average Verbal Comprehension — SS = 118 High Average Perceptual Reasoning — SS = 117 High Average

    ATTENTION WAIS-IV Processing Speed — SS = 105 Average WAIS-IV Working Memory — SS = 117 High Average Semantic Fluency (total) 14 T = 31 Mild Impairment FAS Test (total) 42 T = 47 Average Trail Making Test Part A (time) 24” T = 52 Average Trail Making Test Part B (time) 67” T = 43 Average PASAT (3”) (number correct) 51/60 z = 0.1 Average

    VISUOSPATIAL WAIS-IV Block Design ss = 13 High Average Target Cancellation time (errors) 91” (0) — WNL Rey Complex Figure copy 31/36 — WNL

    LANGUAGE WAIS-IV Vocabulary — ss = 14 Superior Boston Naming Test 58/60 — WNL


    Learning Trial 1 3/16 z = -2.5 Moderate Impairment Learning Trial 5 9/16 z = -1.0 Low Average Total Learning Trials 33/80 T = 39 Low Average Interference Trial 4/16 z = -1.0 Low Average Short Delay Recall 7/16 z = -0.5 Average Long Delay Recall 7/16 z = -0.5 Average Recognition (hits) 14/16 z = 0 Average Recognition (false positive errors) 4/16 z = 0.5 Average

    Wechsler Memory Scale-IV Logical Memory I 31/50 ss = 12 High Average



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    Logical Memory II 27/50 ss = 12 High Average Visual Reproduction I 41/43 ss = 13 High Average Visual Reproduction II 41/43 ss = 16 Superior

    EXECUTIVE FUNCTIONS WAIS-IV Similarities — ss = 13 High Average WAIS-IV Matrix Reasoning — ss = 13 High Average WCST 64 cards (categories) 3 z = -0.3 Average

    MOOD Beck Depression Inventory-II 25/63 — Moderate depression

    *Based on age and/or education-matched normative data (as available) WNL = within normal limits based on clinical impression; SS = standard score; mean = 100, standard deviation = 15; ss = scaled score; mean = 10, standard deviation = 3; T = T-score; mean = 50, standard deviation = 10; z = z-score; mean = 0, standard deviation = 1


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