The Assessment Report Process

Interviews

&

Reports

Assessment Report - The PurposeAssessment Report: A written summary and

synthesis of all of the elements of the assessment. Report will also include treatment recommendations.

Requirements for Valid Assessment Reports:The Examiner:

1. Conducts effective interviews

2. Administers assessments proficiently

3. Writes reports skillfully

The information gathered is pertinent to the purpose

Uses of Assessment Reports 1. Provide answers to referral questions

2. Provide insight for client therapy

3. Assist in the case-conceptualization process

4. Develop treatment options

5. Suggest educational services for students with special needs

6. Offer direction for vocational rehabilitation

services

7. Offer treatment options for those who have

suffered cognitive impairment (brain injury, senility)

8. Assist courts with difficult decisions

9. Provide evidence for job and school

placement

10. Challenge institutional decisions

Information GatheringTo insure relevant, valid, & appropriate

information, take into account the breadth and depth of your assessment procedures:

Breadth: “Cast a wide net.” Make sure you gather enough pertinent information for the purpose of the assessment

Depth: Dependent on the purpose for which the client is being assessed

1. Assessment techniques must reflect the

intensity of the issue

Examiner-Client Relationship

Vital Components for Valid Assessments:1. Establish trust and rapport

2. Insure and Assure confidentiality

*Assessment reliability and validity depend on client trust.

Clinical InterviewsAdvantages of Clinical Interviews:

1. Sets tone for the types of information to be gathered

2. Allows the client to relax about the personal information he/she will share

3. Allows examiner to “tune in” to the client’s

body language while discussing sensitive

information

4. Allows examiner to learn the client’s problem areas

5. Allows examiner and client to decide whether they can work together

Types of Interviews

Structured: Uses pre-established questions to

assess a broad range of

behaviorsUnstructured: Examiner asks questions based

on client responsesSemi-structured: Examiner uses prescribed

items but allows the examinee

to “drift” during interview

The Structured InterviewExaminee responds to pre-established items

Advantages:1. Offers broad areas of content (topics) that

examiner may otherwise miss or forget to ask

2. Increases reliability of results by insuring that all prescribed items will be covered

3. Examiner will cover all items because they are

listed

4. Insures that no items will be missed due to interviewer or interviewee embarrassment

The Structured InterviewDisadvantages:

1. Examiner may miss important information due to stringent adherence to the pre-determined items

2. Examinee may feel that interview is dehumanizing

3. Clients may misinterpret or be unfamiliar with certain items

4. Examiner is less likely to follow-up when client experiences confusion than with other types of interviews

5. Does not always allow examiner to probe more deeply due to the focus on completing all items

The Unstructured Interview

Examiner has no pre-established items to cover. Examinee responses to inquiries set the direction for follow-up questions.

Advantages:1. More conducive to rapport-building

2. Client feels he/she is directing interview, so he discusses items that he deems important

3. Examiner can focus on potentially sensitive areas and, hopefully, uncover issues the client may be withholding

The Unstructured Interview

Disadvantages:1. Examiner may miss items that should be covered

because he is “caught up” in client’s story

2. Because it is client-led, the examiner may spend more time on some items than may be helpful

The Semi-Structured Interview

Uses prescribed items while allowing the client the flexibility to discuss, in more detail, potentially emotion-filled topics.

Advantages:

1. Allows examiner to gather necessary information in short amount of time

2. Allows more opportunity for rapport-building

Computer-Driven AssessmentSophisticated assessment device that

generates well-written report.

Advantages:1. As reliable (or more reliable) as structured

interviews

2. Can provide an accurate diagnosis at minimal cost

3. Final assessment reports are very sophisticated

Remember: Test questions are determined by the examiner and test validity relies on the appropriate selection of test questions.

Assessment Selection

Choose the assessment technique that is uniquely suited to the purpose of testing

Writing the ReportThings to include:

1. Demographic information

2. Problem/Reason for referral

3. Family background

4. Significant medical/counseling history

5. Substance use and abuse

6. Educational & vocational history

7. Pertinent information

8. Mental status

9. Assessment results

10. Diagnosis

11. Summary & conclusions

12. Recommendations

Report: DemographicsDemographic Information to Include:

1. Name

2. Address

3. Phone number

4. E-mail address

5. Date of Birth

6. Age

7. Gender

8. Ethnicity

9. Date of Interview

10. Name of Interviewer

Report: Problem/Reason for Referral

Reason for referral will include:1. Name of person who referred the client

(self-referred, physician, or counselor)

2. Explanation as to why the client has come for counseling or been referred for assessment

Report: Family BackgroundFamily background section will include:

1. Where individual grew up

2. Gender and ages of siblings

3. Whether client came from intact family

4. Who were major caretakers

5. Significant others who impacted client’s life

6. Important/pertinent stories from childhood that influenced how client defines him/herself

7. For adult clients: Marital status, relationship issues, ages and genders of children, & significant others

Report: Significant Medical/Counseling History

Medical/Counseling History Section Includes:

1. Physical conditions that may be affecting the client’s psychological state

2. History of counseling

Report: Substance Use/Abuse

Substance Use/Abuse Section Includes:

1. Use and abuse of legal or illegal substances that may be addictive or potentially harmful

Abuse of: Cigarettes Alcohol Prescription medication Illegal drugs

Report: Educational & Vocational History

Educational & Vocational History Section Includes:1. Description of client’s educational background

2. Discussion of client’s job path & career focus

Report: Other Pertinent Information

Pertinent Information Section Includes:

1. Any information that has not been discussed previously in report

Examples include: Sexual orientation Changes in sexual desire Sexual dysfunction Current or past legal problems that may be affecting functioning Financial problems

Report: Mental Status

A mental status exam assesses the client’s appearance, behavior, emotional state, thought components, and cognitive functioning. Helps in diagnosing and treatment planning

Report: Mental Status ExamExam Sections

Appearance & Behavior:

1. Reports client’s observable appearance

& behaviors during clinical interview

Includes: Dress Hygiene Body posture Tics Significant non-verbal behaviors

Report: Mental Status ExamExam Sections

Emotional State:

1. Description of client’s affect and mood Affect: Current, prevailing feeling

(happy, sad, joyful, angry, depressed)

Mood: Long-term, underlying emotional

well-being (assessed through client self-

report)

(depressed)

Report: Mental Status Exam Exam Sections

Thought Components:

1. The way in which a client thinks reveals how he/she understands and makes meaning of the world

Examiner makes statements about thought content by addressing whether the client has delusions, distortions of body image, hallucinations, obsessions, suicidal or homicidal ideation

Thought Processes: Expressed as circumstantiality, coherence, flight of ideas, logical thinking, intact as opposed to loose associations, organization, & tangentiality

Report: Mental Status ExamExam Sections

Cognition:

1. Includes the following: a) Statement regarding whether the client is oriented

to time, place, and person

b) Assessment of the client’s short- and long-term memory

c) An evaluation of the client’s knowledge base and intellectual functioning

d) Statement about the client’s level of insight and ability to make judgments.

Report: Assessment Results

Assessment Results Should Include:

1. List of assessment procedures used

2. Assessment results, converted to standard scores, presented in language that is unbiased and easily understood

Do not present interpretations until the summary and conclusion sections - if at all.

Report: DiagnosisDiagnosis section presents the clinical diagnosis based

upon the entire assessment process using the criteria from the Diagnostic and Statistical Manual (DSM-IV-TR; APA, 2000).1. Axis I: Clinical Disorders & Other Conditions That May Be a

Focus of Clinical Attention

2. Axis II: Personality Disorders & Mental Retardation

3. Axis III: General Medical Conditions

4. Axis IV: Psychosocial & Environmental Problems

5. Axis V: Global Assessment of Functioning (GAF Scale)

*Provide complete information about client’s experiences on all five axes.

Report: Summary and ConclusionsSummary Section Should Include: This

section should pull together all the information in previous section.

1. Information should be accurate, succinct, and relevant

2. Inferences must be logical, sound, defendable, & based upon facts that have been previously mentioned in the report

3. A paragraph or two describing the client’s strengths

*Do not add information that has not been discussed previously in the report.

Report: Recommendations

Recommendations should be based on all the information gathered. Recommendations should make logical sense to the

reader Section may be written in paragraph form or listed Examiner’s signature should close this section

Assessment ReportBasic format of the Assessment Report

I.Demographic Information

II.Presenting Problem or Reason for Referral

III.Family Background

IV.Significant Medical/Counseling History

V.Substance Use and Abuse

VI.Educational and Vocational History

VII.Other Pertinent Information

VIII.Mental Status

IX.Assessment Results

X.Diagnosis

XI.Summary and Conclusions

XII.Recommendations

Demographic InformationName:Address:Phone:E-mail:Name of InterviewerDate of Birth:Age:Sex:Ethnicity:Date of Interview:

Presenting Problem or Reason for Referral

Information in this category should include the type of referral (self-referral, doctor referral, etc.)

A brief (short paragraph) summary of the client’s reported situation should be included

Report any assessment that was conducted to assist in determining diagnosis and course of treatment

Family Background

In this category, you should include an overview of the client’s family history – a short biography. This should include information regarding his childhood, relationship with parents and siblings, when he/she met his/her spouse. This category should also include information about the client’s current family life. A mention of his/her feelings regarding his/her relationships with family can be included.

Significant Medical/Counseling History

Discuss the client’s medical history and any medications that he/she is on. Include in this discussion the general dates when major medical issues occurred.

Discuss any counseling history, the time when counseling occurred, and the reason for the counseling.

Substance Use and Abuse

Discuss any legal or illegal drug use, as well as alcohol consumption

Discuss tobacco use (in any form)If you feel that the client’s weight (either

underweight or overweight) may be an indication of a problem (overeating, anorexia nervosa, bulimia, malnutrition, etc.), mention that here

Educational and Vocational History

In this section, discuss the client’s educational and vocational history: schools attended, vocations: type of work, length of time employed at each job, level of satisfaction and enjoyment in each job

Include in this section a discussion regarding the client’s preferred career path

Other Pertinent Information

In this section, summarize the client’s main focus of dissatisfaction and any other information you feel is pertinent

Mental StatusInclude the following information (if it is

relevant): Appearance at first meeting Whether he/she maintained eye contact Whether he/she was oriented to time, place, & person Did he/she seem anxious, nervous, or agitated during first

meeting? Sleep habits Mention whether the client reported feeling depressed or

expressed suicidal thoughts Intellectual ability Include anything that seems relevant to a picture of the

client’s mental status

Assessment Results

First paragraph: List the assessments/tests that were administered to the client.

Remaining paragraphs: Discuss the results of each assessment/test and what the results mean with regard to the client.

Diagnosis

Address the following DSM-IV-TR categories: Axis I: Diagnosis – Diagnostic number and name

(Clinical disorders) Axis II: Diagnosis – Diagnostic number and name

(Personality disorders and mental retardation) Axis III: Diagnosis (General medical conditions) Axis IV: Situation (Psychosocial and environmental

problems) Axis V: Global Assessment of Functioning (GAF)

Summary and Conclusions

This section basically revisits the information you discussed in the previous sections.

Recommendations

In list or bulleted format, present your treatment recommendations

Signature

Place your signature at the end of the report

Appendix A: Codes of Ethics WebsitesAmerican Counseling Association (ACA):http://www.counseling.org/Resources/CodeOfEthics/TP/Home/CT2.aspx

American Association of Marriage & Family Therapy (AAMFT):http://www.aamft.org/resources/LRM_Plan/Ethics/index_nm.asp

American Association of Pastoral Counselors (AAPC):http://www.aapc.org/content/ethics

American Psychological Association (APA):http://www.apa.org/ethics

American Psychological Association: Div. 5: Evaluation, Measurement, & Statistics:Uses APA’s ethical guidelines

Certified Rehabilitation Counselors: http://www.crccertification.com/pages/30code.html

Appendix B: ACA’s & APA’s Code of EthicsAssessment Sections

American Counseling Association: Section E

E.1: General: E.1.a: Assessment; E.1.b: Client Welfare

E.2: Competence to Use and Interpret Assessment Instruments

E.3: Informed Consent in Assessment

E.4: Release of Data to Qualified Professionals

E.5: Diagnosis of Mental Disorders

E.6: Instrument Selection

E.7: Conditions of Assessment Administration

E.8: Multicultural Issues/Diversity in Assessment

E.9: Scoring and Interpretation of Assessment

E.10: Assessment Security

Appendix B: ACA’s & APA’s Code of EthicsAssessment Sections

E.11: Obsolete Assessments and Outdated Results

E.12: Assessment Construction

E.13: Forensic Evaluation: Evaluation for Legal Proceedings

American Psychological AssociationEthical Code: Section 9

Section 9: Assessment

9.01: Bases for Assessments

9.02: Use of Assessments

9.03: Informed Consent in Assessments

9.04: Release of Test Data

9.05: Test Construction

9.06: Interpreting Assessment Results

9.07: Assessment by Unqualified Persons

9.08: Obsolete Tests and Outdated Test Results

9.09: Test Scoring and Interpretation Services

9.10: Explaining Assessment Results

9.11: Maintaining Test Security