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*This is a sample of the written report generated by PsychAssistant. With the exception of this red text this report was generated based on the content of the evaluation form for this fictional client.

Mental Health Center 1234 Somestreet Anytown, AL 55555 (555) 555-1234

Psychological Evaluation

Confidentiality Statement: This report is for professional use only. Further distribution of this report is prohibited without consent.

Name: Jane Person Age: 34 Date of Birth: 9/30/1972 Date(s) of Assessment: 5/20/2007, 6/3/2007

Test/s Administered:

Amen Adult General Symptom Checklist Beck Depression Inventory-II (BDI-II) Minnesota Multiphasic Personality Inventory-II (MMPI-II) Shipley Institute of Living Scale

Reason for Referral:

Jane was referred by St. Joe's Hospital. They requested a psychological evaluation after an inpatient stay at St. Joe's Hospital due to suicidal thoughts and behaviors.

Family of Origin:

Jane is of Hispanic ethnicity. Jane was born in New Mexico. She was also raised in Arizona and Texas. Jane's parents are still married. Jane was physically abused by her father. She was sexually abused by her grandfather. She was verbally abused by her father and mother. Jane does not have fond memories of her childhood. In particular, her father was cruel to her both verbally and physically. The physical abuse stopped when she became a teenager but to this day, he continues to speak to her in a demeaning manner. She recalls being molested by her grandfather on at least one occasion. She told her parents who were sympathetic but did not go to the authorities. Jane has had little contact with her grandfather since.

Her mother is a high school graduate. She works in business. Her mother has had the following medical problems: Endometriosis and Irritable Bowel Syndrome (IBS). She has had the following mental health problems: Bipolar Disorder. She has had the following AODA problems: Alcoholism. Her

relationship with her mother is somewhat conflictual.

Her father is a high school graduate. He works in management. Her father has had the following medical problems: Psoriasis. He has had the following mental health problems: Depression and Anxiety. He has had the following AODA problems: Alcohol abuse and Cannabis use. Her relationship with her father is highly conflictual.

Jane has a 32-year-old brother named Kyle. Her brother has a college degree/s. Her brother has worked in sales. Jane's brother had these mental health problems:

Gambling addiction. Her brother has had the following AODA issues: Alcohol abuse. Jane and Kyle have a satisfactory relationship.

Jane has a 25-year-old sister named Sarah. Her sister has a college degree/s. Her sister has worked in education and social services. Her sister has had the following medical problems: Ulcers. Jane's sister has had these mental health problems: Depression, Panic attacks. Her sister has had the following AODA issues: Sedatives/hypnotics/anxiolytics use. Jane and Sarah have a distant relationship.

Social:

Jane has a 34-year-old husband named Troy. Jane's husband has a college degree/s. Troy works in computers. Her husband has had the following medical problems: Chronic Back Pain and Diabetes - Type II. Jane's husband has had these mental health problems: Anxiety. Her husband has had the following AODA issues: Opioids use. Jane and her husband have been together for 13 years . Jane and Troy have a very good relationship. Jane reported no occurrences of domestic violence. Her and her husband have had difficulties due to Jane's mood swings and alcohol binges; however, they have never separated. Jane explained that sometimes she feels she has the best husband in the world and other times she feels that she despises him. They are also having financial difficulties and can barely pay their monthly bills.

Jane had a previous boyfriend. The relationship lasted 2 years. Their relationship was somewhat conflictual. Jane reported no occurrences of domestic violence.

Jane has a 11-year-old son named Sam. Sam is in elementary school. Her son has had the following medical problems: Asthma. Jane's son has had these mental health problems: Learning Disability. Jane and Sam have a very good relationship. Sam has had moderate behavioral problems. Jane has used yelling and groundings to discipline Sam.

Jane has an 8-year-old daughter named Jenny. Jenny is in elementary school. Her daughter has had the following medical problems: Allergies. Jane's daughter has had these mental health problems: Oppositional Defiant Disorder and Attention Deficit/Hyperactivity Disorder (ADHD). Jane and Jenny have a highly

conflictual relationship. Jenny has had moderate behavioral problems. Jane has used spankings, yelling and time-outs to discipline Jenny.

Jane is currently living in a home in New Mexico. She is residing with her daughter, husband and son. Jane has also lived in Nevada.

Jane has a few friends. She occasionally has contact with her friends. Jane likes exercise, movies, music, shopping and television. Jane's religious beliefs follow Christianity.

Jane has had difficulty maintaining friendships because she becomes angry with her friends when they are not there for her every time she needs them. She often ends her friendships and finds new friends.

Education:

Jane has a graduate/professional degree/s. She has received mainly A's and B's in school. Jane had special education for emotional disturbance. Jane had to repeat kindergarten. Jane had many detentions. She had frequent truancies. Jane completed a Master's Degree in business.

Employment:

Jane is currently employed. Her current jobs include:

Self employed for 7 years Homemaking

Her previous jobs include:

Clerical for 9 months Retail sales for 5 months Restaurant service for 6 months Cashier for 1 month

Jane has been fired one time in her employment history. Jane operates a small business out of her home involving sales through the internet. She was fired from her job in fast food restaurant for "horseplay" during work hours.

Medical:

Jane has the following medical conditions:

Allergies for the past 34 years Overactive Bladder for the past 4 years Hypothyroidism for the past 5 years

Jane is taking the following medications:

Claritin

Synthroid

Detrol LA

Jane has had the following medical problems in the past:

Meningitis in 1994 Post-Partum Depression in 1995 Post-Partum Depression in 2000 Her mother had exposed Jane to maternal smoking when she was pregnant. Jane had her last physical in 2006. Jane's last menses was two weeks ago. She had 2 live child births.

Mental Health:

She received psychological testing by Riverside Elementary School in 1980. Jane was hospitalized at St. Joe's Hospital in 2007 for 1 week. She was also hospitalized at St. Joe's Hospital in 2005 for a period of 2 weeks. Jane has had the following diagnoses in the past:

Axis I

305.00

Alcohol Abuse

300.02

Generalized Anxiety Disorder

296.30

Major Depressive Disorder, Recurrent, Unspecified

Axis II

301.83

Borderline Personality Disorder

Jane was evaluated by a school psychologist in 1982, which resulted in her being placed in special classes for emotional disturbances. She was in the psychiatric ward at St. Joe's Hospital twice for suicidal ideation and/or behavior.

Jane has been taking the following medication/s:

300 mg Wellbutrin for the past 3 years. 2 mg Xanax for the past 1 year.

She has taken these medications in the past: Prozac, Zoloft, Zyprexa and Seroquel.

Jane attempted suicide in 1997 by cutting. She also attempted suicide in 1999 by overdosing. Jane has engaged in the following methods of self mutilation: cutting and picking. Jane has reported that she has been aggressive towards others by breaking things, threatening and throwing things.

AODA:

Jane is currently drinking alcohol in heavy amounts daily. She is currently drinking caffeine in moderate amounts daily. She was using cannabis a few times in the past. She was using cocaine once in the past. She was using hallucinogens once in the past. She was using inhalants a few times in the past. She received the following treatment for AODA issues: Alcoholics Anonymous and support group. Jane has been passing out and having black outs several times per week due to her drinking. She has also been sick with hangovers almost daily. She does have a desire to cut back on her drinking, however in the past when she has

tried she has had some physical withdrawal symptoms such as tremors. She stated that she drinks to cope with the stressors in her life, such as the problems she has with her youngest son and the bills that they often can't pay each month due to the minimal income she brings in working out of her home. She only attended AODA meetings a few times and did not feel that they were helpful.

Legal:

Jane has had tickets for speeding and traffic violations. She has sometimes driven as much as 30 miles over the speed limit.

Jane had the following non-criminal lawsuits or other court cases:

Lawsuit: sued by Person/Organization: Joe Somebody Year: 2004 Outcome:

won Case: bankruptcy Year: 2005

Joe Somebody sued Jane for driving her car on to their yard and into their garage door. They won the lawsuit and Jane is now paying monthly toward the $25,000 Joe was awarded. Jane and her husband had to claim bankruptcy in 2005 due to their excessive debt, largely because of Jane's shopping sprees during times when she was filled with energy. She often bought many of the same types of things over and over and felt she couldn't control this. For example, she would buy seven different colors of the same shirt.

Symptoms:

Jane reported the following symptoms: sadness, irritability, anger, guilt, suicidal ideation, obsessions, compulsions, very high energy, low energy, increased appetite, decreased appetite, weight loss, weight gain, insomnia, hypersomnia, visual hallucinations, euphoria, low motivation, low self esteem and poor attention span. Jane reported that she fluctuates between episodes of being extremely happy and full of energy and motivation to accomplish large tasks and then eventually leading to episodes during which she is extremely depressed for weeks on end. In the past, when she was prescribed Zoloft and Prozac for depression, she has spiraled into these "highs." During the highs, she engages in excessive spending, driving fast, and cleaning sprees. She also experiences some auditory hallucinations during these highs. She also reported engaging in checking, organizing, and cleaning in excess of the normal person. She does this to help rid herself of terrible thoughts and images that constantly bother her. This is why she has been largely self-employed because all of these symptoms have interfered with her ability to maintain steady employment. She denied that she is currently having any suicidal ideation and that in fact she has been feeling extremely happy and excited about the unlimited opportunities for growth in her company and hasn't required sleep for a few days. She did speak about her recollections of the abuse she suffered as a child and that it does bother her at times, particularly during episodes of depression. She often fears abandonment from her friends and husband and will cut or pick on her skin. This occurs most

often when she is feeling extremely angry at herself or others.

Observations:

Jane appeared to have been of average weight and of tall stature. Jane looked casual and disheveled in dress, and had appropriate hygiene. Jane wore eyeglasses. She had bodily scar/s . She appeared to be of the stated age. Her speech was fluent, was of normal tone, was pressured and was rapid. She had normal ambulation. She was fidgety and was restless. She was cooperative, friendly and humorous. She made frequent eye contact. Her mood was anxious and cheerful and her affect was labile. She seemed alert and distractible and was oriented to person, place, situation and time. Her immediate memory was poor. Her short-term memory seemed intact. Her long-term memory seemed intact. Jane's thought organization was a flight of ideas and rambling. She offered an excessive amount of information and her insight was limited. Her judgment was limited. She appeared to be functioning in the above average range of intelligence.

Test Results:

Jane completed the Amen Adult General Symptom Checklist and it suggested that she may have a bipolar disorder and obsessive-compulsive disorder. She completed the BDI-II and it suggested that she is not currently depressed. She completed the MMPI-II; however, she produced an invalid profile. She appeared to be answering the questions in a random, haphazard manner and skipped many questions. Jane was administered the Shipley Institute of Living Scale and her overall intelligence was estimated to be in the high average range.

Diagnosis:

Axis I:

303.90

Alcohol Dependence

300.3

Obsessive-Compulsive Disorder

296.42

Bipolar I Disorder, Most Recent Episode Manic, Moderate

Axis II:

301.83

Borderline Personality Disorder

Axis III:

 

Allergies Hypothyroidism Overactive Bladder

Axis IV:

Axis V:

Problems with primary support group Economic problems GAF = 55-65 (current)

Impressions:

Jane meets the criteria for the diagnoses listed above which are likely due, at least partly, to biological or genetic factors given that both of her parents have a history of mental health and AODA problems. She has a history of abuse from

several key individuals in her life and it likely still affects her as an adult. It will be helpful for Jane to address the way in which she views the people in her life in dichotomous ways, identify healthier coping mechnanisms rather than self-harm, aggressive behaviors, and alcohol use, stabilize her moods, and look at the possible ways that her childhood has affected her and may be creating destructive patterns in her present-day relationships.

Recommendations:

Alcoholic's Anonymous or an alternative support group Continued medical care Dialectical behavioral therapy Exposure and response prevention Individual psychotherapy Monitor for risk of suicide Monitor self-harm Outpatient AODA treatment Psychiatric care Psychotropic medication/s

Thank you for this referral. Please contact me if I can be of any further assistance.

John Doe, Ph.D. Licensed Psychologist