Example of Psych Evaluation Report

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December 02, 2011

NEURO-PSYCHOLOGICAL EVALUATION REPORT

GENERAL DATA: Subject is Ms. X, 20 years old, female, single and a resident of__________. She is a 4th year student of the University of X and is currently doing her internship at _______Mental Health Care Center.

MENTAL STATUS AND PSYCHOLOGICAL ASSESSMENT RESULTS: A set of psychological tests was given to Ms. X on November 21, 2011. At that time, she was oriented to date, place and person with good registration and language comprehension skills. Her calculation and capacity for immediate recall were fair. Her overall cognitive functioning at the time of evaluation was considered normal.

A brown-skinned, medium-built, adult female, adequately clad in corporate attire was seen. Fair eye contact was noted. Test results revealed an orderly and self-oriented person who seemed timid and evasive. She has the tendency to be precarious and obsessive-compulsive with paranoid tendencies and expressions of anxiety. She may feel insecure and indecisive at times and may tend to overcompensate for her inadequacies. She seemed to feel quite constricted with her environment and may want to break out of this constriction. She may have acting-out tendencies with a need to grasp and maintain control. She tends to be domineering and demanding and may show a need for emotional satisfaction. In social situations, she may tend to fit into a social stereotype or be what other people expect her to be. She tends to be guarded and defensive. However, she seemed well-balanced, has good organization skill and good ego integration. Generally, she seemed in control with no serious psychological disturbance.
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