Sample Psychological Report

PSYCHOLOGICAL ASSESSMENT REPORT

STRICTLY CONFIDENTIAL Name

: Billy Dela Cruz

G e n d er

:

Date of Birth

:

Date of Testin

:

Chrono!oi"a! Ae

: (Date of testing minus the date of birth)

Ed#"ationa! Stat#s

:

Ci$i! Stat#s

:

Ethni"it%

:

Re!iion

:

O""#&ation

:

Address

:

Conta"t N#m'er(s

:

I)

P*RPOSE O+ E,AL*ATIO E,AL*ATION

Billy was referred by Dr. Juan Dela Cruz, a psychiatrist from 123 Medical Cent Center er,, for for a psy psycholo choloi ica call e!al e!alua uati tion on due due to se!e se!era rall pers person onal al conc concer erns ns whic which h sinificantly affect affect his e!eryday functionin. functionin. Billy complained of persistent persistent insomnia, which he said he had since hih hih school. "n the a!erae, Billy sleeps for #ust #ust about an hour a day. $e would o to bed in the mornin, around %&'' to (&'' )M, )M, or at noon from 12&'' to 1&'' *M. +hree years ao, he was e!aluated e!aluated for insomnia at the leep Center Center in -/ $ospital. 0n 2''%, he was dianosed by Dr. Dr. Dela Cruz with Bipolar Bipolar Disorder and underwent underwent pharmacolo pharmacoloical ical treatment treatment and and indi!idu indi!idual al psychoth psychotherapy erapy..

$e tried tried to

understand his disorder disorder by readin about it. $e claimed that in spite of studies studies sayin that his conditi condition on is treatable, treatable, he said his would only come come and o. ) wee wee prior to consult, Billy uestioned,  What is the use of living if we are all going to die someday? 4 $e said that his condition has otten worse and that he needs to now where he is oin. $e claimed to feel hopeless sometimes about life. +his +his e!alu e!aluati ation on is bein bein undert undertae aen n to better better unders understan tand d Billy Billy5s 5s curren currentt socioemotional and intellectual intellectual functionin. functionin. +he results of this assessment assessment are deemed helpfu helpfull in comin comin up with with possi possible ble inter! inter!en entio tions ns that that can addres addresss Billy Billy5s 5s curren currentt concerns.

6or 7ducational *urposes "nly.

II)

BAC-GRO*ND IN+ORMATION

Personal and Family Histor y Billy was born to parents )malia, 8' years old, and Bernard, 82. $is Manila9born mother, who raduated from 123 Collee with a deree in $otel and :estaurant Manaement, is currently worin as a writer. $is father, who hails from Cebu, is a businessman.

Billy has 2 brothers. Charles, the eldest of the three, is 23 years old, a

collee raduate and is presently worin for their father. +he youner siblin, 189year old Donald is a hih school freshman. +he family is resides in a pri!ate subdi!ision in ;ito Cruz, Manila. +hey used to li!e with their paternal randparents but then they mo!ed out 1' years ao.

Billy describes his relationship with his mother as all riht4 and fine.4 $e finds his mother supporti!e and claimed that she was ne!er really hard on them when it comes to discipline. $is mother wanted Billy to o bac to school, for him to et a routine, and to show some bacbone4 or to become more self9reliant and independent. Billy does not tal much with his father nowadays, which is different from how they were when Billy was youner. Billy said that bac then, he and his father ot alon well. $e lies his father5s bein ambitious but dislies his bein controllin, o!erbearin and bein too authoritati!e. $is father also reprimands him for not doin well in school. )ccordin to Billy, he is closest to his older brother because of their small ae ap. Billy5s parents passed on their faith to their children. +hey practice $induism but Billy claims that he practices the reliion !ery loosely.

Billy describes his childhood as both happy and unhappy. )t an early ae, he reconized that he already has emotional and beha!ioral problems. $e remembers bein piced on by his classmates in rade school for bein a loner. $e was also sicly when he was a child. $e contracted respiratory illnesses and often had couh and colds.

Billy first attended school at <8% *rimary, where he stayed from =inder to (

th

rade. $e finished four years in hih school at an international school. >ooin bac, Billy said that he could ha!e done better in hih school if only he too his classes seriously.

?pon raduatin from hih school, Billy went to (@A ?ni!ersity, where he


too up $otel and :estaurant Manaement. $e lied 7nlish and abstract sub#ects such as *hilosophy. Billy said that his rades in collee were pretty ood and he ot alon with his professors. $e is currently tain a year off from collee because he does not feel as moti!ated in finishin his deree.

Billy made friends in collee. $e claimed that he forets his concerns when he is with them. $owe!er, his closest friends are now li!in abroad that he only ets to be with them durin summers and Christmas breas. +hey lie oin out, watchin mo!ies, and drinin occasionally. $e described himself as a social driner,4 who only drins alcoholic be!eraes when out on occasional atherins.

Billy has been ha!in difficulties sleepin since hih school. +hree years ao, he was eamined at the leep Center in -/ $ospital and was ad!ised on his sleep hyiene. $is psychiatrist prescribed him :emenon but he only too it for 1' days. 0n collee, Billy ot mauled while withdrawin cash from an )utomated +eller Machine. 0t was in o!ember 2''% when he went to Dr. -a!ier aain because he felt that somethin was wron with him.

Dr. -a!ier dianosed him with Bipolar Disorder.

=nowin the

symptoms of this disorder, Billy claims that he is more depressed than manic. $e had <' sessions of neurotherapy, which he claimed did not help. $e attended the sessions twice a wee. $e also attended 1 therapy session with Dr. :a!ine, a psycholoist and Dr. -a!ier5s associate. $is doctor prescribed anti9depressants but he did not tae his medications as ad!ised. +o better understand his condition, Billy tried readin about his disorder. $e remembers readin a study which stated that there is no cure for his Bipolar Disorder.

>ast summer, Billy fell and hurt his nee and shoulder. $e too Celebre, an anti9inflammatory dru, and underwent physical therapy. 0n spite of this, he oes to the ym and boes 3 to < times a wee. )side from hittin the ym, he spends his spare time readin, watchin mo!ies, playin !ideo ames and playin the uitar.

Billy is currently worin as a bartender. $e has been in this #ob for more than a month since the assessment. $e finds his #ob interestin but it can et hectic at times and can et out of hand. $e said that he has a pretty ood relationship with his superiors that


they e!en help him at wor. +hen aain, he said that if earnin a li!in was not a concern, Billy would ha!e wanted to #ust play the uitar.

Billy does not now what he lies about himself. $e epects a lot more from himself and if he could chane a thin in his life, he said that he would ha!e studied more in hih school. $e does not ha!e future plans and dreams, althouh he claimed that he !alues money and a comfortable life, happiness and self9fulfillment, power and influence o!er others.

III)

INSTR*MENTS ADMINISTERED

Multidimensional )ptitude Battery Culture 6air 0ntellience +est Myers9Bris +ype 0ndicator 1% *ersonality 6actors Draw9)9*erson +est ac5s entence Completion +est

I,)

BEHA,IORAL OBSER,ATIONS

Billy came in for testin a little late than his scheduled time. $e was dropped off by their dri!er and went in the clinic by himself. tandin approimately 8511 tall, Billy has a muscular built. $e has stron facial features with deep9set eyes and rouhly sha!en beard. $e appeared well9empt in his red statement shirt, a pair of pair of denim pants and flip9flops. $e was freuently smilin at the beinnin of the assessment and was enerally relaed.

Buildin rapport was relati!ely difficult as Billy could not respond easily to simple uestions, unless elaborated with eamples. e!ertheless, he comfortably shared stories about his family and peers. Billy communicated better in 6ilipino .

Billy showed interest in the initial tas of drawin human fiures by sayin aya4 $e immediately wored on the tas after the instructions were i!en. $e also lauhed and looed ecited at the beinnin of the test when the test administrator #ust used estures to communicate instructions to him.


Billy enaed in tal in the initial tass but was obser!ed to be uiet in the latter part of the assessment. $e seemed to be easily discouraed when he felt lie he was not doin the tas correctly. 6or instance, Billy was reminded and encouraed to narrate stories out of the i!en pictures instead of describin what was on it. $e #ust epressed, “hindi kasi ako magaling sa ganyan e.4 )lthouh he continued worin on the tas, he appeared uninterested to finish it .

6ollowin directions was also difficult for Billy. Directions were only followed nearly correctly after more than one trial of the tas. Ehile repeatin the instructions helped him perform better, estures of the assessor such as pointin to the paper and noddin of head were also obser!ed to be helpful. Durin times when his attention wandered, callin his attention and remindin him to focus on the tas helped .

Billy stayed on his seat in the entire assessment period. $e #ust stood up and waled out of the room when instructed. +owards the end, the assessor ased if he ot tired. $e #ust shoo his head and responded  hindi4 while smilin.

,) TEST RES*LTS AND INTERPRETATION

A) Inte!!e"t#a! +#n"tionin

M#!tidimensiona! A&tit#de Batter%

;erbal ubtests

caled core

0nformation

83

Comprehension

82

)rithmetic

81

imilarities

8<

;ocabulary

<(

*erformance ubtests

caled core

Diit ymbol

<'

*icture Completion

8<


patial

*icture )rranement

88

"b#ect )ssembly

<(

um of caled core

0F

Cateory

;erbal 0F

1'1

)!erae

*erformance 0F

A'

)!erae

+#!! S"a!e I.

/0

A$erae

Billy obtained a 6ull cale 0F of A% classifyin his coniti!e functionin in the )!erae rane. +his suests adeuate reasonin and problem sol!in abilities. $owe!er, the amount of discrepancy between his ;erbal and *erformance 0F5s, 1'1 and A' respecti!ely, hints at sills that are better de!eloped than the others.

) closer loo at his ;erbal subtests re!eals his relati!e strenth in eneralization and abstraction. +his implies that he has accumulated a wide fund of nowlede about di!erse topics that may be attributed to his le!el of curiosity, etensi!eness of readin, and the moti!ation to learn new thins. 0n addition, he does not only ha!e the capacity to store information in his lon9 term memory but is also capable of applyin these nowlede in e!eryday life situations.

$is scores on the *erformance subtests re!eal his relati!ely hih ability to decode !isually presented stimuli, to abstract their intent and meanin, and to interate these perceptions into a meaninful pattern at a i!en time. +hese also reflect adeuate perceptual abilities and sufficient social intellience, permittin insiht on other5s beha!iors and e!aluation of alternati!e outcomes. 6urthermore, he has sufficient capacity to distinuish critical from unessential details i!en pictorial cues. Billy5s !isual9motor sills were found wantin. $is ability to wor with this hand and his sill in processin information are comparati!ely inadeuate. +his may also reflect poor persistence and moti!ation, which are necessary to efficiently carry out such a tas.

C#!t#re +air Inte!!ien"e Test

:aw core& *ercentile& 0F&


G+et eplanation of C60+ :esultsH

B. So"ia! and Emotiona! +#n"tioning

Billy is an introspecti!e and socially sensiti!e youn adult, whose capacity for control and tolerance for stress, especially in terms of interpersonal relationships, are weaened by his poor self9concept and stron feelins of inadeuacy. $e has the ability to form impressions of himself, to interpret the actions of others and to percei!e e!ents as how they appear. $owe!er, his unwillinness to process emotional stimulation may mae him indifferent to his own feelins and to other people. Compared to most people his ae, Billy seems to be much less willin to in!ol!e himself in affecti!ely chared situations, thus, may brea off interpersonal interactions and become emotionally and socially withdrawn. :elationships are percei!ed as somethin that may pose unrealistic demands on him.

+houh he can conduct himself appropriately in social

situations, he does not in!est much emotion and does not re!eal much of himself to others. Eith his poor sense of self and low self9esteem, Billy may thin that he is incapable of dealin with his en!ironment.

Billy is self9critical and has a neati!istic perception of himself. $e has low estimate of personal worth that he may be comparin himself unfa!orably towards other people who are more able, more attracti!e or more efficient than him. $e may e!en be comparin himself to sinificant people around him, such as his father, whom he deems successful. 6urthermore, Billy tends to e!aluate his present self aainst his old self, when he was youner, who is more able and has more acceptable reasons to become passi!e and dependent. >ie a child, Billy is reliant, has a tendency to be stubborn and insecure of himself.

)lthouh it was ascertained that he

intentionally a!oids focusin on himself, he is inclined to be self9centered, who sees attention and uidance. )!oidin self9focusin may be his means to eep his percei!ed inadeuacies out of his consciousness. Eith these, he eperiences low self9esteem and lacs confidence that he cannot assert himself in social situations.

0n an en!ironment that he percei!es as o!erwhelmin, stressful and e!en danerous and threatenin, Billy may feel wea and incapable . Ii!en his low self9esteem, unwillinness to et


in!ol!ed in affecti!ely chared situations, and his limited moti!ation to sol!e conflicts, Billy may resort to the fastest way to alle!iate problems, which is to a!oid them or to deal with them on an intellectual le!el, de!oid of emotions. $e mo!es away from interpersonal relationships to a!oid possible conflicts.

Eith limited social interaction, Billy may not ha!e de!eloped enouh

sensiti!ity to properly decode other people5s actions or reactions. e!ertheless, self9imposed isolation may mae him feel that he is not part of the en!ironment, that he is unaccepted and that people may e!en be actin aainst him.

$e mispercei!es e!ents that at times, he cannot

distinuish what is actually happenin aainst what he thins is happenin.

Billy has unaddressed and unepressed feelins of aner or resentment towards other people or the world in enera l. Because of this, he may display oppositional beha!ior and may defy authorities. +his is liely to foster further ad#ustment difficulties. $e also tends to direct these frustrations towards himself. 0nstead of looin at the bier picture, he may blame himself for the untoward e!ents happenin around him.

:esults also re!eal Billy5s familial concern s. $e feels that he is in conflict with certain members of his family. +houh he somehow reconizes his parents5 support, he stronly feels pressured and looed down on by them. Billy also feels that his parents misunderstand him. Moreo!er, he ets intimidated by his father5s dominance and wishes that his father would not be so condescendin. e!ertheless, he feels a certain affinity for his older brother, Charles, because of their small ae ap.

Despite his passi!ity and e!asi!eness, Billy still stri!es for strenth9 physically, intellectually and emotionall y.

$e wants to be ood in sports. $e wants to do well in school

and to become successful in the future. $e hopes to be a musician. Most of all, Billy stronly desires self9contentment. $e epressed yearnin to finally become happy. $owe!er, he may not now how to satisfy these needs. $e wants to et out of his current situation, which he deems unpleasant. $e wishes to be relie!ed of his sadness and uilt of not performin well in school when he was youner. $e stronly yearns for a sound foundation that will pro!ide him feelins of security and will con!ey support. $e is currently ha!in difficulties in identifyin the sources of his problems that he lons for direction to enlihten him and to help him meet his aforementioned needs. $e belie!es that somehow his en!ironment, thouh danerous, may also be his source of comfort and enlihtenment.


Eith unmet needs due to percei!ed lac of support, his neati!istic !iew of his en!ironment and his depleted self9esteem, Billy feels helpless and anious.

$e may et

disappointed with himself for his past underachie!ements. $is inability and reluctance to foster meaninful interpersonal connections may mae him appear unconcerned and indifferent but in reality, he feels empty and lons contact. Billy seems too distressed by his numerous concerns but feels incapable in resol!in them that he feels maredly depressed.

,I)

S*MMARY

(Summary of entire reort from resenting roblem to results and interretation)

,II)

1.

RECOMMENDATIONS

Billy will benefit from reular and sustained indi!idual psychotherapy. +he followin therapy oals may be included in the formulation of his therapy plan&

a.

Ii!en his stron need for uidance and direction in order to help him satisfy his other needs, Billy needs to de!elop effecti!e copin strateies to help him deal with situations that he finds threatenin or o!erwhelmin. $e may be tauht strateies to help him efficiently deal with life difficulties. $is therapist may consider helpin Billy dispute his misperceptions about himself, his social en!ironment, and about his condition as well.

b.

+herapy may also in!ol!e helpin Billy identify his interests and oals, which may moti!ate him to become proacti!e in addressin his needs and in fulfillin his dreams of becomin successful.

2.

Billy5s family may loo into the possibility of underoin family counselin since familial issues are amon Billy5s main concerns. Counselin sessions may address miscommunications in the family, the family member5s epectations of each other, and to identify their strenths and limitations as a family. Moreo!er, it may include *sychoeducation, which can help not only his family members but Billy as well, understand his condition better. Eith better understandin, more appropriate treatment from his family members miht follow suit and the hope that his condition will et better miht be roused.


3.

Billy may also benefit from social sills trainin. +his may help euip him with sills that he needs in order to relate better with other people. +his may also build self9 esteem and may boost his confidence in main interpersonal connections.

<.

Billy may be helped in formin a stron support system at home and at wor so as to help him cope better with life stressors. =nowin that he has a support system to rely on in times of trouble, Billy may not need to a!oid dealin with his problems. Billy may be assisted in identifyin people whom he can immediately turn to when he is in distress.

8.

Ioin to the ym and boin is encouraed. )llow Billy to maintain this physical acti!ity to pro!ide him with a natural enery enhancement and possibly to channel his pent up frustrations. )side from these, eercisin and enain in sports may mae him feel more able and competent.

%.

"nce better and more efficient social sills are de!eloped, Billy may want to consider #oinin clubs or oranizations that would mae him further his abilities to relate with others. +his would not only enable him to carry out learned social sills but may also be an opportunity for him to form friendships, which may also ser!e as his support roup.

(.

+o strenthen the bond between brothers, Billy and his brothers may enae in acti!ities that all three of them en#oy. *erhaps a ame of basetball or any sport, a boy5s niht out or an out of town may help them identify more with each other.

@.

:eular !isits to his psychiatrist for chec9ups are encouraed. $e may still need to undero pharmacoloical treatments alonside psychotherapy so as to help impro!e his condition.

A.

) re9e!aluation after @ months is recommended to ascertain Billy5s proress.

*repared by&


1NAME2 Ps%"hometri"ian3in3trainin


Sample Psychological Report

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