Approximately 25% of adults suffer from a psychological disorder or mental illness (National Alliance of Mental Health, 2014). Although some disorders and illnesses, only mildly affect an individual’s life, others may significantly impair someone’s ability to function. Therapy (i.e. counseling, psychiatry and/or psychotherapy) plays an important role in helping set clients on the path of healing and recovery. As psychologist, your main function is to assess the client’s signs, symptoms, issues and concerns, diagnose the client’s condition, develop an appropriate treatment plan and write an a psychological evaluation report. If you are a “new” psychologist and wondering how to effectively write a psychological evaluation report – you have come to the right place. This blog will help you effectively write your first psychological evaluation report.
Listed below are the steps to writing an effective psychological report:
The first thing you will want to do when developing your psychological evaluation report is to document the client’s demographics. In other words, you will need to write down the client’s name, address, age, race, educational and/or job status and gender. You may also document the client’s sexual orientation, depending on the client’s issue. You will need to acquire a folder to place the client’s information in. (The folder will be placed in a locked filing cabinet). Place the client’s case number on the outside of the folder and at the top of your report. Also, make note of the date of the evaluation and your report on the outside of the folder. The top of your psychological evaluation report should contain all pertinent client information so that you can readily access it later.
Next you should make note of the location of the treatment/therapy/counseling session. Include the facility’s address, contact person, email address and phone number. It is important that you notate the contact information for the facility, in case you need to refer back to the facility for clarity or additional information
• Background and Current Information
You will also want to collect and document the client’s background. In other words, you will want to explain how long the client has had the issues, condition, psychological disorder and/or mental illness. What has he/she done to treat the condition? How does the client cope with his/her issues and/or condition? What type of childhood did he/she experience? What is the client’s most traumatic experience? What is the client’s happiest memory? How does the client cope with challenging and stressful situations? How does the client feel about himself/herself and others? Has the client sought counseling or therapy in the past? If so, what was the outcome? How does the client feel now? Is the client happy or sad most of the time? How does the client rate his/her quality of life? What would the client like to change or improve? It is important to find out this information because it will help others who may treat the client in the future recognize “flares” and maladaptive patterns of behaviors.
After you have documented the demographics of the client and the facility contact information, you will be ready to dive into the purpose of the evaluation. In other words, you will need to explain why the evaluation is being performed. What are you trying to measure or achieve? What is the purpose for the evaluation? Why was the evaluation needed or requested? If the evaluation is linked to a specific event, then make sure to clearly document what happened, how the client behaved and what the outcome was. Do not forget to document the purpose of your report.
• Procedures & Observations
Once you have documented the purpose of the evaluation and the purpose of the report, you will need to describe, in detail, your evaluative procedures and your observations. In other words, document how the psychological evaluation was conducted (i.e. online or in a counseling session), who conducted the evaluation (i.e. you, another psychologist, etc.), how long the evaluation lasted (i.e. 30 minutes, 60 minutes, etc.), the format of the evaluation (i.e. assessment, observations, exercises and/or activities) and the demeanor of the client during the evaluation (i.e. shaky nervous, tense, withdrawn, depressed, manic/overly excited, agitated, angry, etc.). Make sure that you clearly and thoroughly document what type of assessment was used, if one was used, and what procedures were followed. The purpose of documenting your procedures and observations is to allow others to replicate it.
• Results & Recommendations
Lastly, you will need to document the results of the evaluation, your analysis of the results and your recommendations. If the results contained numerical statistics and/or values – clearly explain those values in your report. If possible, make a graph to show the results in various areas (if applicable). Document any factors that may have affected the evaluation results and explain what you plan to do with the results (i.e. diagnosis and/or develop a treatment plan to help clients with a particular psychological disorder or mental illness). Recommend treatment changes or further research studies.
National Alliance on Mental Health. (2014). Mental illness: Facts and numbers. Retrieved from http://www.nami.org/factsheets/mentalillness_factsheet.pdf
National Association of School Psychologists. (2014). Psychological evaluations: What every principal should know. Retrieved from http://www.nasponline.org/resources/principals/Psychological%20Evaluations%20Nove mber%2003.pdf
National Institute of Mental Health. (2014). Mental health statistics. Retrieved from http://www.nimh.nih.gov/statistics/index.shtml