need to make Psychological Assessment Report. i have mentioned the point that i required. you just need to write detailed paragraph on mention headings. all information is given below. paragraph must be detailed Identifying Information Referral Source and Presenting Problems Interviewing Information Tests Administered Psychological Evaluation Behavior during Sessions Prognosis Conclusion Recommendations
i need to make Psychological Assessment Report. i have mentioned the point that i required. you just need to write detailed paragraph on mention headings. all information is given below. paragraph must be detailed
- Identifying Information
- Referral Source and Presenting Problems
- Interviewing Information
- Tests Administered
- Psychological Evaluation
- Behavior during Sessions
- Prognosis
- Conclusion
- Recommendations
Personal Data
Name of the client: Mr BT ( for example )
Gender: Male
Date of birth: 27/01/1995
Marital status: Unmarried
Education: Graduated
Family Information
Name of Father – Mr Brown ( 56 years)
Name of Mother – Mrs Pery ( 54 years)
1.Presenting Problem -I feel no interest in doing activities, hopeless, and worthless.
From the last past few months, I feel changes in my behaviour, I don’t feel good and active, I lost interest in activities, sometimes I feel helpless and worthless, because of all these thoughts I sometimes get a panic attack.
- I have undergone treatment and therapies for the management of depression 2 years back. My physician in 2019 prescribed me Fluoxetine, there are no adverse reactions to that treatment.
3.Patient medical history – I consume alcohol every day currently not facing any medical issues.
4.Family History – We are 4 members in family. My dad Mr Brown is hypertensive and mom Mrs. Pery is a diabetic patient. Our family income is sufficient to fulfil the requirements of the family. We all share a good bond.
5.School history – An average student during my school days and face issues due to overweight. Students used to bully me. My bond with school teachers is good because I am good at extracurricular activities.
6.History of Friendship – We are a group of 3 friends and I prefer travelling with them in past, but now due to work and life they all are engaged.
7.Work /occupational history: I worked as a Marketing executive it’s a very hectic job, I feel stressed because of work.
Yes, working in a different company in the same position.
Position – Marketing Executive
No, I am not satisfied with job, work overload is extreme and I wish to grow in my field.
Yes, stress due to work overload and working conditions.
Sleep – Unable to sleep during the night.
Attention – Memory and concentration level is good.
Perception – Not present
Thought – The thought process is good and clear.No unusual thought present.
Affect – Guilty of not being able to achieve my goals in life. Client is depressed and guilty.
Behaviour – Normal
Mannerisms and Posturing – Normal gestures
Anxiety – Tension and Obsessions present
Psychosexual Problems – Not present
Addiction – Alcohol addiction
Family psychopathology – No history of treatment related to mental disorders.
Personality trait – Obsessive-compulsive disorder present, anti-social and passive.
Interview Behaviour – Cooperative
Strength – No strengths and talent ( as explained by the individual )
Tentative Diagnosis – Depression
Strengths and power is absent
Dealing with my situations and guilt
Goals for therapy
Able to manage the feeling of hopelessness and worthlessness
Recommendations
1.Hamilton rating scale
2.Zung Scale
3.Toxicology test for screening depression
Final diagnosis – Depression
Date of Termination – I terminated my previous treatment in June 2019
Reason for termination – Due to workload not able to manage therapies and sessions.\
Depression is very common mental health issue and is usually manifested by feelings of individual hopelessness, patient feels worthless and guilty, sometimes the patient also suffers from suicidal thoughts and psychotic features including hallucinations and delusions.
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