NAME:

AGE:

SEX:

RACE:

MARITAL STATUS:

GRADE LEVEL:

OCCUPATION: if adult

DATE OF EXAMINATION:

PLACE OF EXAMINATION:

REFERRAL SOURCE: who referred the client

REFERRAL QUESTION AND STATEMENT OF PURPOSE: hypothesis(es) about the client's presenting concern(s)

EVALUATION PROCEDURES: Mental Status Exam, SII, NEO-PI, MMPI-2

TEST BEHAVIOR AND OBSERVATIONS: Mental Status Exam and other pertinent information about the client's behavior during testing, particularly that which may qualify subsequent test results

BACKGROUND INFORMATION: significant case-history information (e.g., medications, prior treatment) and "current" events in the client's life (e.g., home and family environment, current relationships, hobbies, religious practices); for children, include developmental information and family constellation

RESULTS AND INTERPRETATION: present test results and integrate these data with information about the client's behavior and background.  Orient the interpretation around the hypothesis(es) previously made regarding the person's difficulty(ies).  Address the client's level of functioning as you judge it from the data (e.g., self-concept, coping style or defenses, interpersonal functioning, family dynamics, functional analysis; the interpretation may reflect, in part, your theoretical orientation).

RECOMMENDATIONS: recommendations should follow logically, clearly, and compellingly from previous sections of the report