Sie sind auf Seite 1von 7

*This is a sample of the written report generated by PsychAssistant.

With the exception of this


red text this report was generated based on the content of the evaluation form for this fictional
client.

Mental Health Center


1234 Somestreet
Anytown, AL 55555
(555) 555-1234

Psychological Evaluation
Confidentiality Statement: This report is for professional use only. Further
distribution of this report is prohibited without consent.
Name: Jane Person
Age: 34
Date of Birth: 9/30/1972
Date(s) of Assessment: 5/20/2007, 6/3/2007
Test/s Administered:
Amen Adult General Symptom Checklist
Beck Depression Inventory-II (BDI-II)
Minnesota Multiphasic Personality Inventory-II (MMPI-II)
Shipley Institute of Living Scale
Reason for Referral:
Jane was referred by St. Joe's Hospital. They requested a psychological
evaluation after an inpatient stay at St. Joe's Hospital due to suicidal thoughts and
behaviors.
Family of Origin:
Jane is of Hispanic ethnicity. Jane was born in New Mexico. She was also raised
in Arizona and Texas. Jane's parents are still married. Jane was physically abused
by her father. She was sexually abused by her grandfather. She was verbally
abused by her father and mother. Jane does not have fond memories of her
childhood. In particular, her father was cruel to her both verbally and physically.
The physical abuse stopped when she became a teenager but to this day, he
continues to speak to her in a demeaning manner. She recalls being molested by
her grandfather on at least one occasion. She told her parents who were
sympathetic but did not go to the authorities. Jane has had little contact with her
grandfather since.
Her mother is a high school graduate. She works in business. Her mother has
had the following medical problems: Endometriosis and Irritable Bowel
Syndrome (IBS). She has had the following mental health problems: Bipolar
Disorder. She has had the following AODA problems: Alcoholism. Her

relationship with her mother is somewhat conflictual.


Her father is a high school graduate. He works in management. Her father has
had the following medical problems: Psoriasis. He has had the following mental
health problems: Depression and Anxiety. He has had the following AODA
problems: Alcohol abuse and Cannabis use. Her relationship with her father is
highly conflictual.
Jane has a 32-year-old brother named Kyle. Her brother has a college degree/s.
Her brother has worked in sales. Jane's brother had these mental health problems:
Gambling addiction. Her brother has had the following AODA issues: Alcohol
abuse. Jane and Kyle have a satisfactory relationship.
Jane has a 25-year-old sister named Sarah. Her sister has a college degree/s. Her
sister has worked in education and social services. Her sister has had the
following medical problems: Ulcers. Jane's sister has had these mental health
problems: Depression, Panic attacks. Her sister has had the following AODA
issues: Sedatives/hypnotics/anxiolytics use. Jane and Sarah have a distant
relationship.
Social:
Jane has a 34-year-old husband named Troy. Jane's husband has a college
degree/s. Troy works in computers. Her husband has had the following medical
problems: Chronic Back Pain and Diabetes - Type II. Jane's husband has had
these mental health problems: Anxiety. Her husband has had the following
AODA issues: Opioids use. Jane and her husband have been together for 13
years . Jane and Troy have a very good relationship. Jane reported no
occurrences of domestic violence. Her and her husband have had difficulties due
to Jane's mood swings and alcohol binges; however, they have never separated.
Jane explained that sometimes she feels she has the best husband in the world and
other times she feels that she despises him. They are also having financial
difficulties and can barely pay their monthly bills.
Jane had a previous boyfriend. The relationship lasted 2 years. Their relationship
was somewhat conflictual. Jane reported no occurrences of domestic violence.
Jane has a 11-year-old son named Sam. Sam is in elementary school. Her son
has had the following medical problems: Asthma. Jane's son has had these
mental health problems: Learning Disability. Jane and Sam have a very good
relationship. Sam has had moderate behavioral problems. Jane has used yelling
and groundings to discipline Sam.
Jane has an 8-year-old daughter named Jenny. Jenny is in elementary school.
Her daughter has had the following medical problems: Allergies. Jane's daughter
has had these mental health problems: Oppositional Defiant Disorder and
Attention Deficit/Hyperactivity Disorder (ADHD). Jane and Jenny have a highly

conflictual relationship. Jenny has had moderate behavioral problems. Jane has
used spankings, yelling and time-outs to discipline Jenny.
Jane is currently living in a home in New Mexico. She is residing with her
daughter, husband and son. Jane has also lived in Nevada.
Jane has a few friends. She occasionally has contact with her friends. Jane likes
exercise, movies, music, shopping and television. Jane's religious beliefs follow
Christianity.
Jane has had difficulty maintaining friendships because she becomes angry with
her friends when they are not there for her every time she needs them. She often
ends her friendships and finds new friends.
Education:
Jane has a graduate/professional degree/s. She has received mainly A's and B's in
school. Jane had special education for emotional disturbance. Jane had to repeat
kindergarten. Jane had many detentions. She had frequent truancies. Jane
completed a Master's Degree in business.
Employment:
Jane is currently employed. Her current jobs include:
Self employed for 7 years
Homemaking
Her previous jobs include:
Clerical for 9 months
Retail sales for 5 months
Restaurant service for 6 months
Cashier for 1 month
Jane has been fired one time in her employment history. Jane operates a small
business out of her home involving sales through the internet. She was fired from
her job in fast food restaurant for "horseplay" during work hours.
Medical:
Jane has the following medical conditions:
Allergies for the past 34 years
Overactive Bladder for the past 4 years
Hypothyroidism for the past 5 years
Jane is taking the following medications:
Claritin
Synthroid
Detrol LA

Jane has had the following medical problems in the past:


Meningitis in 1994
Post-Partum Depression in 1995
Post-Partum Depression in 2000
Her mother had exposed Jane to maternal smoking when she was pregnant. Jane
had her last physical in 2006. Jane's last menses was two weeks ago. She had 2
live child births.
Mental Health:
She received psychological testing by Riverside Elementary School in 1980.
Jane was hospitalized at St. Joe's Hospital in 2007 for 1 week. She was also
hospitalized at St. Joe's Hospital in 2005 for a period of 2 weeks. Jane has had the
following diagnoses in the past:
Axis I
305.00 Alcohol Abuse
300.02 Generalized Anxiety Disorder
296.30 Major Depressive Disorder, Recurrent, Unspecified
Axis II
301.83 Borderline Personality Disorder
Jane was evaluated by a school psychologist in 1982, which resulted in her being
placed in special classes for emotional disturbances. She was in the psychiatric
ward at St. Joe's Hospital twice for suicidal ideation and/or behavior.
Jane has been taking the following medication/s:
300 mg Wellbutrin for the past 3 years.
2 mg Xanax for the past 1 year.
She has taken these medications in the past: Prozac, Zoloft, Zyprexa and
Seroquel.
Jane attempted suicide in 1997 by cutting. She also attempted suicide in 1999 by
overdosing. Jane has engaged in the following methods of self mutilation: cutting
and picking. Jane has reported that she has been aggressive towards others by
breaking things, threatening and throwing things.
AODA:
Jane is currently drinking alcohol in heavy amounts daily. She is currently
drinking caffeine in moderate amounts daily. She was using cannabis a few times
in the past. She was using cocaine once in the past. She was using hallucinogens
once in the past. She was using inhalants a few times in the past. She received
the following treatment for AODA issues: Alcoholics Anonymous and support
group. Jane has been passing out and having black outs several times per week
due to her drinking. She has also been sick with hangovers almost daily. She
does have a desire to cut back on her drinking, however in the past when she has

tried she has had some physical withdrawal symptoms such as tremors. She
stated that she drinks to cope with the stressors in her life, such as the problems
she has with her youngest son and the bills that they often can't pay each month
due to the minimal income she brings in working out of her home. She only
attended AODA meetings a few times and did not feel that they were helpful.
Legal:
Jane has had tickets for speeding and traffic violations. She has sometimes
driven as much as 30 miles over the speed limit.
Jane had the following non-criminal lawsuits or other court cases:
Lawsuit: sued by Person/Organization: Joe Somebody Year: 2004 Outcome:
won
Case: bankruptcy Year: 2005
Joe Somebody sued Jane for driving her car on to their yard and into their garage
door. They won the lawsuit and Jane is now paying monthly toward the $25,000
Joe was awarded. Jane and her husband had to claim bankruptcy in 2005 due to
their excessive debt, largely because of Jane's shopping sprees during times when
she was filled with energy. She often bought many of the same types of things
over and over and felt she couldn't control this. For example, she would buy
seven different colors of the same shirt.
Symptoms:
Jane reported the following symptoms: sadness, irritability, anger, guilt, suicidal
ideation, obsessions, compulsions, very high energy, low energy, increased
appetite, decreased appetite, weight loss, weight gain, insomnia, hypersomnia,
visual hallucinations, euphoria, low motivation, low self esteem and poor
attention span. Jane reported that she fluctuates between episodes of being
extremely happy and full of energy and motivation to accomplish large tasks and
then eventually leading to episodes during which she is extremely depressed for
weeks on end. In the past, when she was prescribed Zoloft and Prozac for
depression, she has spiraled into these "highs." During the highs, she engages in
excessive spending, driving fast, and cleaning sprees. She also experiences some
auditory hallucinations during these highs. She also reported engaging in
checking, organizing, and cleaning in excess of the normal person. She does this
to help rid herself of terrible thoughts and images that constantly bother her. This
is why she has been largely self-employed because all of these symptoms have
interfered with her ability to maintain steady employment. She denied that she is
currently having any suicidal ideation and that in fact she has been feeling
extremely happy and excited about the unlimited opportunities for growth in her
company and hasn't required sleep for a few days. She did speak about her
recollections of the abuse she suffered as a child and that it does bother her at
times, particularly during episodes of depression. She often fears abandonment
from her friends and husband and will cut or pick on her skin. This occurs most

often when she is feeling extremely angry at herself or others.


Observations:
Jane appeared to have been of average weight and of tall stature. Jane looked
casual and disheveled in dress, and had appropriate hygiene. Jane wore
eyeglasses. She had bodily scar/s . She appeared to be of the stated age. Her
speech was fluent, was of normal tone, was pressured and was rapid. She had
normal ambulation. She was fidgety and was restless. She was cooperative,
friendly and humorous. She made frequent eye contact. Her mood was anxious
and cheerful and her affect was labile. She seemed alert and distractible and was
oriented to person, place, situation and time. Her immediate memory was poor.
Her short-term memory seemed intact. Her long-term memory seemed intact.
Jane's thought organization was a flight of ideas and rambling. She offered an
excessive amount of information and her insight was limited. Her judgment was
limited. She appeared to be functioning in the above average range of
intelligence.
Test Results:
Jane completed the Amen Adult General Symptom Checklist and it suggested
that she may have a bipolar disorder and obsessive-compulsive disorder. She
completed the BDI-II and it suggested that she is not currently depressed. She
completed the MMPI-II; however, she produced an invalid profile. She appeared
to be answering the questions in a random, haphazard manner and skipped many
questions. Jane was administered the Shipley Institute of Living Scale and her
overall intelligence was estimated to be in the high average range.
Diagnosis:
Axis I:
303.90
300.3
296.42
Axis II:
301.83
Axis III:

Alcohol Dependence
Obsessive-Compulsive Disorder
Bipolar I Disorder, Most Recent Episode Manic, Moderate
Borderline Personality Disorder
Allergies
Hypothyroidism
Overactive Bladder

Axis IV:
Axis V:

Problems with primary support group


Economic problems
GAF = 55-65 (current)

Impressions:
Jane meets the criteria for the diagnoses listed above which are likely due, at least
partly, to biological or genetic factors given that both of her parents have a
history of mental health and AODA problems. She has a history of abuse from

several key individuals in her life and it likely still affects her as an adult. It will
be helpful for Jane to address the way in which she views the people in her life in
dichotomous ways, identify healthier coping mechnanisms rather than self-harm,
aggressive behaviors, and alcohol use, stabilize her moods, and look at the
possible ways that her childhood has affected her and may be creating destructive
patterns in her present-day relationships.
Recommendations:
Alcoholic's Anonymous or an alternative support group
Continued medical care
Dialectical behavioral therapy
Exposure and response prevention
Individual psychotherapy
Monitor for risk of suicide
Monitor self-harm
Outpatient AODA treatment
Psychiatric care
Psychotropic medication/s
Thank you for this referral. Please contact me if I can be of any further
assistance.
__________________________________________________
John Doe, Ph.D.
Licensed Psychologist