Client History Report Draft
For this assignment, you will write the first four sections of the psychological assessment report that will be completed in Week Five. Taking on the role of a psychological evaluator, you will formulate vitally important methodological and theoretical assessment conceptualizations of a client during the initial phases of the assessment process. You will apply your conceptualizations to develop a clear understanding of the presenting concerns. In the initial sections of your psychological assessment report, you will summarize results obtained from examining the following information pertaining to your client: identifying information, reason for referral, presenting concerns, and relevant personal history. The content of this section must demonstrate an ethically and professionally responsible rationale for the use of psychological assessment tools. View the complete instructions for the Final Paper in the link within Week Five of your online course or the “Components of Course Evaluation” section of this guide. This week, your assignment must cover the following sections of your psychological assessment report and include the headings as listed:
I. Identifying information
Within this section, you will record basic information on your client including the person’s name, sex, gender, ethnicity, sexual orientation, age, handedness, and occupation or grade level. For the purposes of this assignment, you are free to create any relevant demographic information that is not explicitly stated in the case scenario. All information you create must be consistent with the information provided and any conclusions you draw in subsequent sections of your paper.
II. Reason for referral
Within this section describe the referral source and the purpose of the assessment. The information you provide in this section must justify the decision to conduct a formal psychological assessment based and must model ethically and professionally responsible assessment practices.
III. Current Symptoms/Presenting Concerns
The information in this section of the report would typically come from an interview with the client and family (if applicable, e.g., if the client is a child or person with suspected dementia). You must use the information provided in case history to identify the most salient information that belongs in this section. Choose information to include in this section based on the consistency with the reason for referral and purpose for testing. Here is where you will apply your methodological and theoretical assessment formulations of the client that will justify the decision to conduct a psychological evaluation on this client.
IV. Psychosocial History (complete each of the sections below based on the information in the case you selected)
- Educational history
- Occupational history
- Medical history (including substance use/abuse)
- Psychiatric history
- Social history
Your assignment must be of sufficient depth and detail to support and inform your eventual diagnostic impressions. A cursory or surface level review of the client’s presenting problem and history will unlikely provide enough information for your diagnostic impression. The assignment must also include a page with relevant references based on your initial impressions of possible diagnostic considerations from the history that you have reviewed.
- Must be at least 2.5 to 3 single-spaced pages in length (not including title and reference pages).
- Must include a title page with the following:
- Title of paper
- Student’s name
- Course name and number
- Instructor’s name
- Date submitted
- Must use at least 2 scholarly sources, 1 of which must be an original peer-reviewed research article, in addition to the course text.
- Must document all sources in APA style
- Must include a separate title page and reference page that is formatted according to APA style as outlined