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PrivateMosquitoMaster458
interpreted (WAIS-IV, WRAT4, and MMPI-2) you will also add your…
interpreted (WAIS-IV, WRAT4, and MMPI-2) you will also add your interpretation of the PAI Download PAIand the WHODAS Download WHODAS(also located under Resources). report will include a reason for referral (may be fictitious), discussion of the test results from the WAIS IV, WRAT 4, MMPI-2, and PAI, a brief discussion of the WHODAS 2.0,diagnostic impressions, summary and recommendations, based on findings that refer to the referral question(s).
A description of the content for each of the main sections of report follows:
Identification and Referral
· Client’s name, age, marital status, ethnicity, gender.
· Describe the setting, including where the testing took place, how the client travelled there (or if you went to the client’s home).
· Reason for testing at this time, including the referral source (can be a self-referral or a fictitious referrer) and the information sought by the referrer.
· Presenting problems and symptoms.
There should be one or more referral questions to be answered by your assessment. These questions will be answered in your “Recommendations” section and the answers should flow logically from your findings. Some common referral questions for psychological testing include:
· Mental health diagnosis and treatment or management recommendations.
· Disability determination – whether the client is able to work and limitations.
· Vocational/educational assessment – what kind of work would be a good fit for the client’s abilities.
· Learning disability assessment – is a learning disability present and what sort of limitations and accommodations are appropriate.
History
Preface your history by indicating the source (such as client’s report or family report).
Family History. Include information about current family, current living situation and family of origin.
Educational and Vocational History. Level of education completed, high school and college grades, any history of special education, expulsions and suspensions, occupation and jobs held, last worked, reason for any dismissals, longest time at the same job, vocational aspirations if relevant.
Medical and Mental Health History. The non-psychiatric section should include reports of medical diagnoses and symptoms, current medications, surgeries and overnight hospitalizations, and any head injuries. The mental health section should include psychiatric hospitalizations, outpatient mental health treatment, substance abuse treatment, history of psychotropic medication prescriptions, and suicide attempts. When applicable, indicate that there was “no reported history of …” to show that you inquired about the areas above.
Antisocial Behavior/Substance Abuse. Age, charge, and outcome of any arrests or other legal problems. Current and past use of alcohol and other recreational drugs, 12-step group attendance.
Daily Functioning
Client’s mode of travel (car, bus, family rides) and ability (short trips by car, uses the bus but needs help to get to a new location, etc.). Client’s daily living skills, including ability to groom, bathe, dress, do household chores, and manage money. Include a general description of the client’s daily activities including job, recreational, and social activities.
Mental Status and Behavioral Observations
Use the Mental Status Exam form as a guide for your interview. This section can be written or dictated directly from this form.
General appearance: Particularly note unusual characteristics that may provide diagnostic information – neglected hygiene, unusual dress or tattoos, or physical characteristics that may affect the person’s social interactions and abilities. Indicate if the client appeared her/his stated age or younger or older than her/his stated age.
Attitude & general behavior: Describe the person’s interaction with you and attitude toward being tested and interviewed.
Mood and affect: Obtain a quote from the client regarding recent mood. Ask about any history of depression and anxiety. Note the range of the client’s affect. Ask about sleep and appetite, and inquire further about depressive or anxious symptoms if a particular disorder is suspected. See the symptom guide at the bottom of the MSE form. For instance, if PTSD were suspected, you would inquire about symptoms, such as nightmares, flashbacks, and startle response.
