Counseling Assessment Report

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Counseling Assessment Report

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Name:

Date of birth:

Address:

Sex:

Phone:

Race & Ethnicity:

E-mail:

Date/s of assessment:

Examiner:

Date of Report:

Reason for Referral (Note: this section guidelines and comments are adapted/taken from Dr. Krach’s report writing guide and Carol L. Oster, Psy.D.’s website.) (Before beginning any assessment, clarify the questions that the assessment needs to answer. Include the client’s questions, as well as those of third parties. Report the name of the person, system, or committee who referred the client, if any. Report the general, primary reason for referral along with any specific problems (concrete examples), and report any secondary difficulties that are not considered to be the biggest problem. Describe any previous attempts to solve these problems and the success of these attempts. The clearer the reason for the assessment is, the more helpful you can be to the client. Common referral questions are to clarify diagnosis, to assist in differential diagnosis, to assist in treatment planning, to understand treatment impasses, to understand the client’s academic performance, to determine whether the person is qualified for a particular job or academic program, and to answer a particular question or set of questions.) Background and History Background, Family and Social History (Note: this section guidelines and comments are adapted/taken from Carol L. Oster, Psy.D.’s website.) (Write in narrative style –using paragraphs-. Include the information below: • Identifying information including age, sex, race, ethno-cultural identity, marital status, and occupation, whether the person is a student, homemaker or retired. • Presenting complaint and symptoms _____________________________________________________________________________________ [Your company’s name] Page 1 of [total] • History of the presenting complaint including onset, duration, course (times when it’s better or worse) • Prior counseling, psychological or psychiatric treatments and success of these: o With whom, what for, when and for how long o What worked, what didn’t o What the client liked/disliked o Long-term outcome o Relationship with treating clinicians) • The client’s conceptualization of the problem • Relevant personal history • Critical events in development and timeliness of these • Life stressors in the time period preceding the presenting problem and preceding the referral for evaluation (Include the following information on the paragraph on family history: • Adopted or related by blood? • Academic accomplishments and problems in siblings, parents, grandparents, aunts & uncles • Occupational functioning in parents, grandparents, siblings • Relevant medical history: parents, grandparents, siblings • Psychiatric history: parents, grandparents, siblings, aunts and uncles • Level of acculturation of family o Length of time in US o English-language fluency o Conflict or acceptance of US cultural norms relevant to the referral question or diagnoses under consideration. • Permission to speak with family members if relevant and necessary for the assessment • Note: Do not name family members. Refer to them by relationship only. E.g., “Mr. X’s uncle” versus, “John Smith, Mr. X’s uncle”; “older brother” versus “Tom Smith”, Mr. X’s older brother”. • Prior psychological or academic assessment and results at that time. Request copies of previous testing) (Include the following information on the paragraph on social history: • • • • • • • Marital, dating, friendship status Typical social activities and level of involvement in the community Success of social activities as evidenced by length and persistence of relationships Satisfaction/dissatisfaction Quality of interaction with members of peer group, family, and community Any difficulties – onset, course, duration, patterns, situational analysis Capacity to tolerate being alone) _____________________________________________________________________________________ [Your company’s name] Page 2 of [total] Medical History (Note: this section comments are adapted/taken from Dr. Krach’s report writing guide and Carol L. Oster, Psy.D.’s website.) • • • • • • (Write in narrative style –using paragraphs-. There should be one main idea or area per paragraph, with supporting details. Include the information below: Congenital or neonatal history including genetic or congenital disorders Childhood illnesses, particularly ear infections, asthma, injuries, hospitalizations, chronic illnesses, anything that required missing a substantial amount of school either all at one time or cumulatively Later (teen and adulthood) illnesses, especially… • Chronic illnesses, especially if diabetes, thyroid problems, metabolic problems • Fibromyalgia, arthritis, carpal tunnel, or other pain or functional disorder/disease • Multiple sclerosis or other degenerative disease/disorder • Brain injury (TBI, stroke, tumors), Any hospitalizations • What for and when • Length of hospitalizations • Any problems, complications, or sequelae? • Success of treatment Hearing, vision, orthotic, or vestibular problems, • Impact on presenting problem • Corrective measures or treatment • Efficacy of corrective measures • Whether the person is using those corrective measures at the time of testing Medications taken previously or currently; • Type and dosage • What for • Efficacy • Side effects the person experiences • How long they’ve been taking it • Whether they take it regularly as prescribed • Last time they took it (date and time) • If today, “Is it working? How long does it take to “kick in”? Substance Use and Abuse (Note: this section comments are adapted/ taken from Carol L. Oster, Psy.D.’s website.) (Write in narrative style –using paragraphs-. Include the following: _____________________________________________________________________________________ [Your company’s name] Page 3 of [total] • Alcohol and street drugs the person “has tried” • When started, largest amount consumed and when; current types and levels of use in dosage and exact frequency • Last use, context of use/abuse • Effects and impact • Side effects • Legal issues (Consider a formal substance abuse history where indicated.) • Prior efforts to quit • Social system’s reactions to use Educational and Vocational History (Note: this section comments are adapted/taken from Dr. Krach’s report writing guide and Carol L. Oster, Psy.D.’s website.) (Write in narrative style –using paragraphs-. Include the information below for the educational/academic history: • Level of education • Success in school as evidenced by GPA, honors, and similar hard data • Major in college if any • What the person recalls about learning to read and do math • Liked and disliked subjects • Academic strengths and weaknesses • Whether any special assistance or accommodation has been needed or granted before this time • Permission to contact school if relevant and necessary to the evaluation Include the information below for the client’s occupational history: • What the person does for a living • What work they have previously done • Level of accomplishment as evidenced by promotions, added responsibilities, awards, etc. • What the person recalls about learning the job • Strengths and weaknesses • Likes and dislikes • Quality of interactions with peers, supervisors, and supervisees • Whether any special assistance or accommodation has been needed or granted before this time • Permission to speak with employer if relevant and necessary to the evaluation Other Pertinent Information _____________________________________________________________________________________ [Your company’s name] Page 4 of [total] Previous Test Results (Report any previous counseling/psychological assessment or testing results for your client if available. Include when and the reason for previous assessment, and any interventions that were recommended). Evaluation Procedures (Name of client) completed the following assessments: (List any procedures completed, in order of administration.) Behavioral Observations -Note: this section comments are adapted/taken from Dr. Krach’s report writing guide and Carol L. Oster, Psy.D.’s website.) (Keep this section descriptive, not evaluative or conclusive. One paragraph is a reasonable length. Report any particularities related to the testing itself (e.g., two or more sessions, background noise, interruptions in the testing, interference, etc.). “Generally, you want to relate any environmental conditions that might have made it difficult for the client to put forth his/her best effort, or that might have affected the validity of testing.” The Mental Status Exam results pertain to this section. Briefly mention the client’s appearance, behavior and attitude (is the person groomed?, clean?, appears chronological age?, average height and weight for age?, anything unusual about client’s appearance?, does client appear attentive?, motivated?, tired?, wired?, intoxicated?; how did client relate to the examiner –rapport-?). Note client’s orientation to person, place and time, especially in psychiatric, forensic, or rehabilitation/neurological settings. “Observe speech quality, e.g., intonation, modulation, pressure, fluidity, speech problems, as well as reticence or verbosity. Describe the client’s affect (visible display of emotion): feelings displayed, range of expressiveness (flat, labile, animated/normal), and appropriateness to content during the interview and formal testing. List any reported or observed limitations in sensory-motor functioning: glasses or contacts (to correct what?), hearing aid, gait or motor problems, hand tremors, etc. Report on ideation evident in behavior, such as suicidal/ homicidal comments, evidence of delusional or hallucinatory thinking evident in behavior (as opposed to evident in test results).” “In a separate paragraph, report on the client’s apparent attention and concentration, cooperation, persistence, and effort. Then make a statement about the validity of results based on behavioral observations and history. For example, you could say, “Based on Mr. X’s behavior, and his apparent effort and cooperation, test results are likely to be an (accurate, _____________________________________________________________________________________ [Your company’s name] Page 5 of [total] underestimate) assessment of his (typical functioning, functioning at this time, or potential)” (…) “Typical functioning” means you think this is the way the client functions generally, and that the test results are not unduly influenced by situational factors. “Current functioning” means this is the way the client is functioning NOW, but the results may not indicate prior functioning or predict future functioning. This is appropriate when, for example, you are testing a person who is recovering from brain injury, or who is severely depressed. “Potential” indicates you are trying to predict how the person will function in the future, such as on the job, or in school. For example, you might be evaluating a student for special services, and the test results may reflect about how well the student can be expected to perform at his/her best (provided you were able to motivate the student to perform well, and there were no situational or personal constraints). Some examples: “Based upon Mr. Smith’s obvious cooperation, persistence, and effort, these tests results are likely to accurately reflect his true potential.” “Based upon Mr. Smith’s lack of cooperation and difficulty with concentration and persistence, these results likely underestimate his true potential. However, they may accurately reflect his functioning under the current stress of family disruption.” “Based upon Mrs. Smith’s effort, concentration, and cooperation, these results likely accurately reflect her current depressed functioning.” “Based upon the number of interruptions and the less than optimal testing conditions, these results likely underestimate Mrs. Smith’s true score, despite her cooperation, effort, and obvious desire to succeed.” “These test results may slightly overestimate Mr. Smith’s true score, particularly on Performance tasks, due to his familiarity with the test materials.” “Mr. Smith’s history, and his cooperation with the testing procedure, suggest that the results reflect his typical functioning.”) Assessment Results Clinical Symptoms The Beck Depression Inventory, 2nd edition (BDI-II) is a self-report questionnaire designed to measure the severity of general symptoms of depression in adolescents (ages 13 and older) and adults. The BDI yields a total raw score that ranges between 0 and 63. A total raw score _____________________________________________________________________________________ [Your company’s name] Page 6 of [total] of 0 to 13 indicates asymptomatic, symptoms within normal range or minimal; a total raw score of 14 to 19 indicates mild depression; a total raw score of 20 to 28 indicates moderate depression and a total raw score of 29 to 63 indicates severe depression. The client yielded a score of (X) on the Beck Depression Inventory II, which indicates (type here). (In addition, describe what specific items the client endorsed, and determine if those items belong in one of the two groups –factors- in the BDI-II manual: somatic-affective dimension or cognitive dimension of depression. Items that belong in the somatic-affective dimension include: agitation, loss of energy, changes in sleeping pattern, changes in appetite, concentration difficulty, tiredness/fatigue, loss of interest in sex, loss of pleasure, crying, loss of interest, indecisiveness, irritability). Items in the cognitive dimension of depression include sadness, pessimism, past failure, guilty feelings, punishment feelings, self-dislike, selfcriticalness, suicidal thoughts or wishes, and worthlessness.) The Beck Anxiety Inventory (BAI) is a 21-item self-report scale that estimates the severity of anxiety symptoms in adolescents and adults. Total scores for this assessment may range from 0 to 63; scores between 0 and 7 indicate minimal anxiety, scores between 8 and 15 indicate mild anxiety, scores between 16 and 25 indicate moderate anxiety and scores 26 and higher indicate severe anxiety symptoms. (Report the client’s total score and its interpretation (severity level of client’s anxiety). Report which specific items the client rated themselves as having mild/moderate/severe significant changes. Determine if those items belong in one of the four factors reported in the BAI manual: neurophysiological symptoms of anxiety (numbness, wobbliness, dizzy, unsteady, hands trembling, shaky, faint), autonomic aspects of anxiety (hot, indigestion, face flushed, sweating), panic (heart pounding, choking, difficulty breathing, fear of dying), and subjective aspects of anxiety (unable to relax, fear of worst happening, terrified, nervous, fear of losing control, scared.) Achievement The Wide Range Achievement Test – Fourth Edition (WRAT -IV) provides a nationally standardized, norm-referenced test for measuring basic academic skills of word reading, sentence comprehension, spelling, and math computation. This individual’s performance resulted in the standard scores, percentile rank scores, and grade equivalents shown below. The WRAT-IV yields standard scores with a mean of 100 and a standard deviation of 15. Standard scores between 85 and 115 are considered average. Standard Percentile Grade Equivalents Domains Scores Rank Word Reading Sentence Comprehension _____________________________________________________________________________________ [Your company’s name] Page 7 of [total] Spelling Math Computation Reading Composite * *No grade equivalent score is given for this composite measure, which combines word reading and sentence comprehension. (Client’s name) obtained a score in the (see score chart description) range on (insert subtest name here). In addition, a Reading Composite score was generated. The Reading Composite score was calculated by combining the Word Reading and Sentence Comprehension scores. (Client’s name) obtained a score in the (see score chart description) on this composite. (Indicate whether the client’s scores are consistent with his/her educational level. For example, does the person show GE scores in the 12 grade or higher? Achievement scores of 12 or higher are consistent with university studies. Are there any areas that may be causing the client to struggle academically?) Career Interests and Values The O*NET Interest Profiler (O*NET IP) allows users to identify vocational areas that match with their interests by indicating likes or dislikes for 180 various activities, and then pinpointing specific jobs to explore. Jobs are identified from the Department of Labor’s Occupational Information Network, a special database known as the O*NET. The O*NET IP uses six vocational types; Realistic, Investigative, Artistic, Social, Enterprising, and Conventional, and scores identify career areas that match interests and pinpoint specific jobs to explore. A higher number score reflects greater interest for that type. This person’s responses yielded the results shown below. Interest Score Interest Realistic Social Investigative Enterprising Artistic Conventional Score (Client’s name) responses reflect higher interests characterized by the descriptions which follow. _____________________________________________________________________________________ [Your company’s name] Page 8 of [total] (NOTE: PROVIDE ONLY THE DESCRIPTIONS OF THE CLIENT’S TOP 3 CAREER INTERESTS) Realistic (People with realistic interests like work activities that include practical, hands on problems and solutions. They tend to enjoy dealing with plants, animals, and real-world materials such as wood, tools, and machinery. People with realistic interests often do not care for occupations that mainly involve paperwork or working closely with others). Investigative (People with investigative interests like work activities that have to do with ideas and thinking more than with physical activity. They tend to like to search for facts and figure out problems mentally rather than to persuade or lead people). Artistic (People with artistic interests like work activities that have to do with the artistic side of things, such as forms, designs, and patterns. They like self-expression in their work. They tend to prefer settings where work can be done without following a clear set of rules). Social (People with social interests like work activities that assist others and promote learning and personal development. They tend to prefer to communicate more than to work with objects, machines, or data. They like to teach, to give advice, to help, or to otherwise be of service to people). Enterprising (People with enterprising interests like work activities that have to do with starting up and carrying out projects, especially business ventures. They like persuading and leading people and making decisions. They tend to prefer action rather than thought, and may like taking risks for profit). Conventional (People with conventional interests like work activities that follow set procedures and routines. They tend to prefer working with data and details more than with ideas, and to prefer work in which there are precise standards rather than work in which you have to judge things by yourself. They like working where the lines of authority are clear.) [YOU MAY OR NOT HAVE TAKEN THIS TEST, IF YOU ARE NOT SURE ASK YOUR INSTRUCTOR] The O*NET Work Importance Locator (O*NET WIL) helps to explore the work values that are more important to an individual, and the possible occupations that match the person’s top work values. The O*NET WIL uses six major work values: Achievement, Independence, Recognition, Relationships, Support, and Working Conditions, and scores identify groups that tend to include these values and pinpoint specific jobs to explore. The higher the number score, the greater the importance this person places on that value. Results for the O*NET WIL reflect stronger identification or affiliation with the values described below. _____________________________________________________________________________________ [Your company’s name] Page 9 of [total] (NOTE: PROVIDE ONLY THE DESCRIPTIONS OF THE TOP 3 WORK VALUES) Achievement (jobs that let people see the results of their efforts and get a feeling of accomplishment) – (score) Independence (jobs that let people do things on their own initiative and make decisions on their own) – (score) Recognition (jobs with prestige, potential for leadership, and/or good possibilities for advancement) – (score) Relationships (jobs that let people be of service to others, jobs where coworkers are friendly, jobs that do not make people do things that go against their sense of right and wrong) – (score) Support (jobs where the employer has a reputation for competent, considerate, and fair management) – (score) Working Conditions (jobs that let people take best advantage of their particular work style, such as liking to be busy all the time, liking to work alone, or liking to have many different things to do) – (score) Personality The 16 Personality Factor Questionnaire (16 PF) is an objectively scored Instrument designed to measure sixteen functionally independent and psychologically meaningful dimensions of personality. Each factor is rated from one to ten along a continuum which describes the factor. The numerical scale indicates a tendency towards a particular trait; standard ten scores (sten) of four to seven are considered average. Note: You need to report standard ten scores (sten scores) for both 16 primary and 5 global factors. Note that the name of a factor is NOT the same as a descriptor. For example, you can’t get a sten score of 3 on the shyness factor because it does not exist, you can get a sten score of 3 on the social boldness factor, and shy is an adequate descriptor for somebody with a sten score of 3 on that factor. Low score description 1 Emotionally reserved Concrete thinking Emotionally changeable Deferential, cooperative Serious, careful 2 3 4 5 6 7 8 9 10 High score description Attentive, outgoing Abstract thinking Emotionally stable Dominant, forceful Lively, spontaneous _____________________________________________________________________________________ [Your company’s name] Page 10 of [total] Non-conforming Shy, timid Unsentimental, objective Trusting Practical, solutionoriented Straightforward Self-assured, unworried Traditional Group-oriented Flexible Rule-conscious Socially bold Subjective, sentimental Vigilant, suspicious Imaginative, ideaoriented Private, discreet Self-doubting, worried Open to change Individualistic Perfectionist, organized Tense, impatient Relaxed, patient (NOTE: Check your raw score on the Impression Management scale –IM-, if equal to or less than 20 in this scale, you can state that: “The individual has presented a self-image that is neither markedly self-critical nor overly positive.”) (Look at the 16 PF scoring and feedback guide provided to you in class to get ideas to write the client’s 16PF results. Only write on the primary factors in which you obtained sten scores between 1-3 or between 8-10, which make your personality different from other persons. Remember that sten scores lower than 3.5 are in the low range, sten scores between 3.5 – 4.5 are in the low average range, sten scores between 6.5 and 7.5 are high average and sten scores higher than 7.5 are higher than average. You need to provide the sten scores for the five global factors in your write-up: Extraversion, Independence, Tough-mindedness, Selfcontrol, and Anxiety.) Summary (Generally, this should be only one short paragraph for an initial evaluation, and two short paragraphs for a re-evaluation. In a re-evaluation, the first paragraph should focus on previous results and the second should focus on current results. The opening sentence should give a short demographic description of the individual. Each area assessed should have at least one sentence.) Diagnostic Impression (DSM-5) (Note that for some referral questions, diagnosis is not the issue, and no diagnosis should be given. If there is no DSM-5 diagnosis to be made, state so.) Recommendations _____________________________________________________________________________________ [Your company’s name] Page 11 of [total] (You may present recommendations in a numbered outline format or in a paragraph form. A recommendation should be made for each referral question, and tailored for the referring person. For example, if it is a parent referral, then the recommendations should be things to do at home. Recommendations should always be stated positively (e.g., “break long assignments into smaller sections”; avoid using the negative form: “don’t give long assignments), and be based on empirically supported intervention strategies. Group recommendations according to the major findings of the report. You may place major recommendations first, and less critical recommendations later.) (The suggestions to write your recommendations below are taken from Carol L. Oster, Psy.D., Clinical Psychologist website, and may be helpful as well: 1. “Your first point, when needed, should be anything urgent or emergent: the need to hospitalize, to take action to protect the client or others from the client’s dangerousness, to protect the client due to extremely poor reality testing, to urgently have the client assessed for medical or neurological problems. If it’s serious, say so clearly. Further, if something needs to be done emergently, don’t wait for the report to be written to get in touch with the client, their family, the referrer, etc., so that emergency needs can be met immediately. 2. Identify any recommendations that relate directly to the referral question: hire/no hire recommendations, accommodations needed on the job or at school, forensic recommendations where appropriate, and so forth. Common psychological recommendations are identified in the points below. 3. Identify whether psychological treatment is warranted. If so, related to what specific issues? What mode? What kind? What frequency, intensity, setting, and urgency? To achieve what goals? Of what expected duration? Example: “Continued inpatient hospitalization is warranted due to Mr. Smith’s suicidal ideation and plan, concurrent severe anxiety and lack of social support.” “Individual, outpatient, cognitive-behavioral therapy, once weekly, to address Mary’s adjustment to college and separation anxiety is recommended. Mary should begin working with the college counselor this week if possible, as she is considering terminating her enrollment and returning home.” “Ms. Taylor should be referred to Kinheart for participation in “coming out” groups to help her identify and cope with the issues related to her decision to reveal her sexual orientation to her family, and to receive support from others after having been “outed” at work.” 4. Consider medical evaluation? To alleviate what symptoms? _____________________________________________________________________________________ [Your company’s name] Page 12 of [total] Example: “If Mary’s anxiety does not abate within two weeks, the Campus Health Care Center should schedule Mary for a medical evaluation to determine whether antianxiety mediation is needed. Specific attention should be paid to evaluating her sleep pattern at that time, as she reports sleep deprivation due to excessive worry at night.” 5. Further assessment? What kind? By whom (what specialty)? To resolve what questions? Example: “Neuropsychological assessment is recommended to assess the extent and nature of brain damage Mr. Smith has suffered as a result of his substance abuse. Rehabilitation evaluation is recommended to identify interventions that may help him cope with his impairments.” 6. Non-psychological, non-psychiatric interventions needed? What kind? By whom? Other agencies need to be involved? Example: “Given the nature of Mrs. Smith’s cultural and religious beliefs and their impact on her willingness to seek therapy, consultation with and/or referral to her rabbi is recommended. This consultation should identify whether the rabbi is capable of helping Mrs. Smith with her depression, or whether the rabbi can assist her in accepting the professional help she clearly needs.” 7. Environmental interventions needed? Example: “Johnny needs to be seated at the front of each classroom, so that he is able to see the board.” “This employee should be switched to a position that minimizes interaction with customers, and provides him with opportunity to socialize with a small cadre of fellow workers.” 8. Issues that might interfere with treatment and how to address them? Example: _____________________________________________________________________________________ [Your company’s name] Page 13 of [total] “Mary’s parents see her as a victim of “the university’s impersonal, uncaring environment.” They repeatedly sympathize with and encourage Mary’s distress. Unless the parents can be helped to adopt a supportive yet adaptive approach, this student may fail in her transition to college. It is recommended that the Dean of Students arrange to meet with the parents and that they be referred to the Parents-in-Transition outreach program.”) (Signature/s) (Provide your complete name and highest earned and relevant degree in the first line) (Provide any certification or licensure on the second line) (Note: only sign the completed, final draft.) _____________________________________________________________________________________ [Your company’s name] Page 14 of [total] O*NET Interest Profiler: Score Report Your interest results: Realistic Investigative Artistic Social Enterprising Conventional 19 27 20 30 24 5 R I A S E C Realistic Your score: 19 People with Realistic interests like work that includes practical, hands-on problems and answers. Often people with Realistic interests do not like careers that involve paperwork or working closely with others. They like: • Working with plants and animals • Real-world materials like wood, tools, and machinery • Outside work Investigative Your score: 27 People with Investigative interests like work that has to do with ideas and thinking rather than physical activity or leading people. They like: • Searching for facts • Figuring out problems Artistic Your score: 20 People with Artistic interests like work that deals with the artistic side of things, such as acting, music, art, and design. They like: • Creativity in their work • Work that can be done without following a set of rules Social Your score: 30 People with Social interests like working with others to help them learn and grow. They like working with people more than working with objects, machines, or information. They like: • Teaching • Giving advice • Helping and being of service to people Enterprising Your score: 24 People with Enterprising interests like work that has to do with starting up and carrying out business projects. These people like taking action rather than thinking about things. They like: • Persuading and leading people • Making decisions • Taking risks for profits Conventional Your score: 5 People with Conventional interests like work that follows set procedures and routines. They prefer working with information and paying attention to details rather than working with ideas. They like: • Working with clear rules • Following a strong leader Special Notice: Proper Use of O*NET Interest Profiler Results You should use your O*NET Interest Profiler results to explore the world of work and identify careers that may satisfy what is important to you in a job-your interests. You will be able to look at the interests satisfied by careers and compare them to your own interests. Talk to a vocational/employment counselor or teacher for more help on how to use your O*NET Interest Profiler results. Your O*NET Interest Profiler results should not be used for employment or hiring decisions. Employers, education programs, or other job-related programs should not use your results as part of a screening process for jobs or training. If you think that your O*NET Interest Profiler results are being used incorrectly, talk to your vocational/employment counselor, teacher, or program administrator. You also can contact the National Center for O*NET Development for assistance. National Center for O*NET Development Attention: Customer Service P.O. Box 27625 Raleigh, NC 27611 Email: O*NET Customer Service (onet@onetcenter.org) Cl i ni cal Repor t Madeupaf akecl i ent Thei mpor t antel ement sont hecl i ni cal r epor tar e: – Thef i r stpar taboutt he( name: Sal ma, sex : F, age: 31…. .et c.j ustl eav ei tempt yI wi l l f i l l i t) – Reasonf orRef er r al ( y oucanwr i t eher eanxi et yandhomesi ck) – Fami l ybackgr ound( mi ddl eeast er nf ami l y , mul t i cul t ur al f ami l y , st abl ef ami l yno di v or ce, t r adi t i onal st y l ef ami l y , t hef at heri st hebr eadownerandt hemom, st ay athomemom.I ’ mt hesecondol destchi l d, wi t h5si bl i ngs, I ’ v ebeeni nt heUni t ed st at edf or4y ear s, Icameasast udent , – Academi cBackgr ound(bachel ori nPsy chol ogy , Idon’ thav eanywor kexper i ence, Ii mmedi at el yappl yf ort heschol arshi pt ocompl et emyeducat i on)(Ihav eshor t exper i enceonr ehabcent erf orki dswhi l eIwasdoi ngmyt r ai ni ngf ormyf i r st maj or)(Ihav ehi ghabi l i t yt or ecal l andr ememberi nf or mat i on, Il i ket or ead booksi nbot hl anguagesAr abi candEngl i sh, Ispeak2l anguages) – Medi cal hi st or y( nosev eri l l ness, orhospi t al i zef orl ongt i me, t heonl ysur ger yI hadi st onsi l swhenIwas4) – Subst anceabuseanduse( j ustwr i t enon) – Educat i onal andv ocat i onal hi st or y – Ev al uat i onpr ocedur e – Behav i or al Obser v at i ons – Assessmentr esul t s – Cl i ni cal r esul t sf ort hef l owi ngassessment : – BeckDepr essi onI nv ent or y( BDI I I )( Iscor ed18whi chi smi l d) – BeckAnxi et yI nv ent or y( BAI )( Iscor ed30whi chi ssev er e) – WRAT( y ouwi l l f i ndt hescor eswi t ht heat t achment ) – O* NETI nt er estPr of i l er( y ouwi l l f i ndt hescor eswi t ht heat t achment ) – Not e – Iwi l l keepy ouupdat edaboutt het estscor es, assoonasIgett hem) – Thi sassi gnmenthasnor ef er ences – APAst y l e – 5t o6pages, si ngl espace – Pl easef eel f r eei fy ouhav eanyquest i on. – Thi sassi gnmenti sduet he8thofDecember .