Discuss relevant psychological history including previous diagnoses and treatment.

 

Argosy University

Forensic Mental Health Professional Individual Assessment Report

Course FP6020

Name: Identification Number: Date of Birth:

Tests Date: Time Spent:

Interview Date: Time Spent:

Name of Assessment (competency to stand trial, substance abuse, not guilty by reason of insanity, or mental health evaluation).

Introduction

In this section, briefly introduce the main purpose of the evaluation.

Reason for Referral

In this section, discuss the reason this case or individual was referred to you. Also, discuss what you hope to find out about the client and the client’s role in the assessment. The points you make here will be the guides to what interview format and psychological tests you choose and what type of report you will prepare, (recommendations to the court or attorney, competency findings, or treatment recommendations). The interview data, test data, findings, and recommendations will relate to the referral question.

Presentation

In this section, identify interview behavior and review mental status. Discuss cooperation and willingness to discuss pertinent history and current functioning. Identify appearance features with a general description and comments concerning hygiene. Review mental status elements including attention; orientation; thought processes; thought content; short-term, long-term, and immediate memory and recall; comprehension and estimation of intelligence; response to proverbs; awareness of current events; ability to build rapport with the examiner; defenses; affect; mood; speech coherence; eye contact; reasoning ability; reality testing; judgment and impulse control; insight; and concentration.

Current Life Situation

Discuss the client’s current legal and occupational status relationships, and family involvement. Review the client’s perception of the offense, the purpose of the assessment, the case against him or her, and the need to have the assessment. Also, explore the client’s current relationships with professionals in the case, recent stressors, and general methods for coping. Include any pertinent information about this client’s life as it is being experienced currently.

Background Information

Discuss the client’s development, family experiences, abuse, traumas, birth order, mother’s and father’s occupations, family morals, family values, closeness of relationships, educational history, military history, occupational history, and legal history. Also, discuss the history of relationships with friends and spouses and personal and occupational acquaintances.

Psychological History

Discuss relevant psychological history including previous diagnoses and treatment. Also, review the family history of psychological difficulty and treatment.

Substance Use History

Discuss substance use as it relates to the age of the client when first using alcohol, marijuana, cocaine, and other substances. Also, explore abuse and dependence history and factors that sustain use. Discuss the client’s treatment history and any family history of substance use and treatment. Discuss frequency of present use, how it began, what sustains it, periods of sobriety, factors contributing to sobriety (external or internal), obstacles to success with sobriety, family history, previous attempts at treatment, number of relapses, perception of use difficulty, awareness of relapse potential, awareness of risk factors for relapse, and triggers to use and relapse.

Medical History

Review all relevant medical history, medications, and treatments. Explore family medical history.

Objective Testing

Identify the full name of each test, and include descriptions of the purposes for each one used in the assessment.

Example

Tests administered

Minnesota Multiphasic Personality Inventory, second edition (MMPI-2)

The MMPI-2 is a self-administered personality inventory designed to evaluate personality traits and symptoms of psychological illnesses and personal maladaptive adjustment.

Weschler Adult Intelligence Scales, fourth edition (WAIS 4)

The WAIS 4 is a full-scale intelligence test used to identify intellectual functioning and potential deficits in both verbal and non-verbal areas.

Findings

Relate your findings in the format recommended by the test manual. Incorporate your findings with your observations of the client and the self-descriptions the client offered during the interview. Also, include test findings as they relate to collateral information on the client.

Diagnostic Impressions

AXIS I:

AXIS II:

AXIS III:

AXIS IV:

AXIS V:

Conclusion

Summarize your findings by incorporating interview data, test data, collateral information, and mental status elements. Discuss your findings as they relate to your observations of the client and the referral question and purpose of the assessment.

Recommendations

Discuss your recommendations as they relate to the referral question, treatment needs, third party request, and the purpose of the assessment.

Sign your name and credentials. Date your report.

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