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112 W Main, Purcell, OK 73080
Phone: (405) 527-1785 || Fax: (405) 527-1084
www.counseling-ok.com
PSYCHOLOGICAL EVALUATION REPORT
Examinee:
Gender:
Guardian:
Examiner:
Date of Birth:
Age:
Date of Report:
Test Dates:
Reason for Referral
Methods of Evaluation
Clinical Interview
Behavioral Observations
Mental Status Examination
Behavior Assessment System for Children, Third Edition (BASC-3)
Burks Behavior Rating Scales, Second Edition (BBRS-2)
Child Sensory Profile, Second Edition (CP-2)
Conners Rating Scales, Third Edition (Conners-3)
Gilliam Autism Rating Scale, Third Edition (GARS-3)
.
National Institute for Children’s Health Quality Vanderbilt Assessment Scale (NICHQ-VAS)
Patient Health Questionnaire (PHQ-A)
The Severity Measure for Depression
Screen for Child Anxiety Related Disorders (SCARED)
Diagnostic Consideration
Based on the diagnostic scores ________is struggling with
. Additionally, ____ presents with sensory processing difficulties in These findings are consistent
with the DSM-5 diagnosis of __________________________________
Mental Status Examination
Relevant History
***CONFIDENTIAL***
The following psychological assessment report is intended as a communication between professionals. This report
includes sensitive information that is likely to be misinterpreted by those without the necessary training.
Authorization for use of this report is limited to the examinee and their designated consultants. Any further use
requires the authorization of the examinee or their legal guardian. Use or disclosure outside these parameters
constitutes a violation of HIPPA.
CONFIDENTIAL Evaluation- XXXXXXX – Page
2
Evaluation Results
Behavior Assessment System for Children, Third Edition (BASC-3)
The BASC-3 is an individually administered, norm-referenced, comprehensive set of rating
scales and forms designed to inform understanding of the behaviors and emotions of children and
adolescents ages 2 years through 21 years, 11 months. The BASC-3 was scored and interpreted
using software from Pearson Assessments based on the work of Cecil R. Reynolds, PhD &
Randy W. Kamphaus, PhD. The interpretive profiles are included below. No validity issues
were noted in patterns of responding.
This report is based on the caregiver’s rating of the child’s behavior using the BASC-3 Parent
Rating Scales Form as well as the child’s completion of the BASC-3 Self-Reporting Scales form.
The narrative and scale classifications in this report are based on the T-Scores obtained using
norms. Scale scores in the Clinically Significant range suggest a high-level of maladjustment.
Scores in the At-Risk range may identify a significant problem that may not be severe enough to
require formal treatment or may identify the potential of developing a problem that needs careful
monitoring.
BASC-3, Parent Rating Scale
Scale
Hyperactivity
Aggression
Conduct Problems
Externalizing Problems
Anxiety
Depression
Somatization
Internalizing Problems
Attention Problems
Atypicality
Withdrawal
Behavior Symptom Index
Adaptabilty
Social Skills
Leadership
Functional Communication
Activities of Daily Living
Adaptive Skills
BASC-3, Self-Rating Scale
Scale
Hyperactivity
Aggression
Conduct Problems
T-Score
Percentile
Description
T-Score
Percentile
Description
***CONFIDENTIAL***
The following psychological assessment report is intended as a communication between professionals. This
report includes sensitive information that is likely to be misinterpreted by those without the necessary
training. Authorization for use of this report is limited to the examinee and their designated consultants. Any
further use requires the authorization of the examinee or their legal guardian. Use or disclosure outside these
parameters constitutes a violation of HIPPA.
CONFIDENTIAL Evaluation- XXXXXXX – Page
3
Externalizing Problems
Anxiety
Depression
Somatization
Internalizing Problems
Attention Problems
Atypicality
Withdrawal
Behavior Symptom Index
Adaptability
Social Skills
Leadership
Functional Communication
Activities of Daily Living
Adaptive Skills
Results of the parent’s rating on the BASC-3 indicated that the patient exhibits Clinically
Significant Behaviors in the area of XXXXX. At-Risk behavior was seen in the areas of
XXXXX. All other areas were rated within normal limits. Results of the patient’s BASC-3
indicated that the patient exhibits Clinically Significant Behaviors in the area of XXXXX. AtRisk behavior was seen in the areas of XXXXX. All other areas were rated within normal limits.
Burks Behavior Rating Scales-Second Edition (BBRS-2)
The Burks Behavior Rating Scale (BBRS-2) scales identify the nature and severity of
pathological symptoms in children from Prekindergarten through 12th grade. The BBRS-2 helps
diagnose and treat children with behavior problems.
Scales
Disruptive Behavior
Attention/Impulse Control
Emotional Problems
Social Withdrawal
Ability Deficits
Physical Deficits
Weak Self-Confidence
T-Scores
80+
80+
80+
80+
80+
60
80+
Response Validity
I-Scale: 47
F-Scale: 80+
**Interpretive guidelines for T-scores suggest scores >60 are of clinical concern.
***CONFIDENTIAL***
The following psychological assessment report is intended as a communication between professionals. This
report includes sensitive information that is likely to be misinterpreted by those without the necessary
training. Authorization for use of this report is limited to the examinee and their designated consultants. Any
further use requires the authorization of the examinee or their legal guardian. Use or disclosure outside these
parameters constitutes a violation of HIPPA.
CONFIDENTIAL Evaluation- XXXXXXX – Page
Disruptive Behavior (DB)
Poor Anger Control (ANG)
Distrustfulness (DISTRUST)
4
Social Withdrawal (SW)
Withdrawal (WTDRL
Social Isolation (SOCIS)
Aggressive Tendencies (AGG)
Rebelliousness (REB)
Poor Social Conformity (PCONF)
NICHQ Vanderbilt ADHD Diagnostic Rating Scales
The Vanderbilt ADHD Diagnostic Rating Scale (VADRS) is a psychological report assessment
tool for Attention-Deficit/Hyperactivity Disorder (ADHD) symptoms and other related disorders
and their effects on behavior and academic performance in children ages 6-12.
The patient’s caregiver and teacher responded to the VADRS questions. Results of the VADRS
indicated that the patient exhibits clinically elevated symptoms commonly seen in AttentionDeficit/Hyperactivity-Predominantly. Hyperactivity/Impulsive type and Oppositional Defiant
Disorder. Functional impairment was indicated in the following areas: XXXXXXXXX. NO
elevation in mood related symptoms were noted.
Scores
Scales
Inattentive
Hyperactive/Impulsive
Oppositional Defiance
Conduct Disorder
Anxiety/Depression
Parent
Teacher
Scoring
Inattentive – Positive Score on 6 out of 9 behaviors with 1 positive score in performance.
Hyperactive/Impulsive- Positive score on 6 out of 9 behaviors with 1 positive score in performance.
Oppositional Defiant- Positive score on 4 out of 8 behaviors with 1 positive score in performance.
Conduct Disorder- Positive score on 3 out of 14 behaviors with 1 positive in performance.
Anxiety/Depression- Positive Score on 3 out of 7 behaviors with 1 positive in performance
Child Sensory Profile 2
Sensory Section
Auditory Processing
Visual Processing
Raw Score
14
15
Percentile Range
12-85
11-82
Classification
Like Others
Like Others
***CONFIDENTIAL***
The following psychological assessment report is intended as a communication between professionals. This
report includes sensitive information that is likely to be misinterpreted by those without the necessary
training. Authorization for use of this report is limited to the examinee and their designated consultants. Any
further use requires the authorization of the examinee or their legal guardian. Use or disclosure outside these
parameters constitutes a violation of HIPPA.
CONFIDENTIAL Evaluation- XXXXXXX – Page
Touch Processing
Body Position Processing
Oral Processing
Movement Processing
30
13
50
25
97-99
10-89
96-99
96-99
Much More Than Others
Like Others
Much More Than Others
Much More Than Others
43
41
36
97-99
86-96
94-99
Much More Than Others
More Than Others
Much More Than Others
76
52
68
46
98-99
87-96
97-99
87-96
Much More Than Others
More Than Others
Much More Than Others
More Than Others
Behavioral Processing
Conduct
Social/Emotional
Attentional
Quadrant Score Summary
Seeking/Seeker
Avoiding/Avoider
Sensitivity/Sensor
Registration/Bystander
Screen for Child Anxiety Related Disorders (SCARED)
Total= 52
Panic Disorder/Significant Somatic Symptoms (PN): 11
Generalized Anxiety Disorder (GD): 15
Separation Anxiety Disorder (SP): 7
Social Anxiety Disorder (SC): 14
Significant School Avoidance (SH): 5
Positive Screenings
Total >/= to 25= presence of anxiety disorder
PN >/= to 7
GD >/= to 9
SC >/= to 8
SH >/= to 3
Gilliam Autism Rating Scale-Third Edition
Subscale Performance:
Subscales
Raw Scores
Restricted/Repetitive 8
Behavior (RB)
Social Interaction
15
(SI)
Percentile Ranks
25
Scaled Scores
8
SEMs
1
16
7
1
***CONFIDENTIAL***
The following psychological assessment report is intended as a communication between professionals. This
report includes sensitive information that is likely to be misinterpreted by those without the necessary
training. Authorization for use of this report is limited to the examinee and their designated consultants. Any
further use requires the authorization of the examinee or their legal guardian. Use or disclosure outside these
parameters constitutes a violation of HIPPA.
5
CONFIDENTIAL Evaluation- XXXXXXX – Page
Social
Communication
(SC)
Emotional
Responses (ER)
Cognitive Style (CS)
Maladaptive Speech
(MS)
21
37
9
1
24
91
14
1
2
3
16
16
7
7
1
1
Composite Performance
Subscale Scaled Scores
Sum of
%ile
Composites
RB SI SC ER CS MS
Scaled Scores
Probability Severity
Autism Index
Very Likely
(4 Scores)
8
2
7
Autism Index
Very Likely
(6 Scores)
8 7
2
9 14
-
-
9 14 7 7
31
Autism
Ranks
Index
38
51
52
97
89
SEMs
4
4
Summary
INTERVENTION RECOMMENDATIONS
Treatment Recommendation:
Intervention strategies suggested for treatment of ADHD include:
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Classwide Peer Tutoring
Computer-Assisted Instruction
Contingency Management
Daily Behavior Report Cards
Modified-Task Presentation Strategies
Multimodal Interventions
Parent Training
Self-Management
Task Modification
Intervention strategies suggested for treatment of Anxiety include:
***CONFIDENTIAL***
The following psychological assessment report is intended as a communication between professionals. This
report includes sensitive information that is likely to be misinterpreted by those without the necessary
training. Authorization for use of this report is limited to the examinee and their designated consultants. Any
further use requires the authorization of the examinee or their legal guardian. Use or disclosure outside these
parameters constitutes a violation of HIPPA.
6
CONFIDENTIAL Evaluation- XXXXXXX – Page
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Cognitive-Behavioral Therapy Integrated Approach
Cognitive Restructuring
Contingency Management
Exposure-Based Techniques
Modeling
Psychoeducational Approach
Relaxation Training
Self-Monitoring and/or Self-Assessment
Parent Training
Self-Management
Task Modification
Intervention strategies suggested for treatment of Autism Spectrum Disorder include:
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Early Intensive Interventions
Applied Behavioral Analysis
Social Skills Training
Cognitive Behavioral Therapy
Intervention strategies suggested for treatment of Depressive Disorder:
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Cognitive behavioral Therapy
Dialectical Behavioral Therapy
Interpersonal Psychotherapy
Mindfulness-Based Cognitive
Family Therapy
Intervention strategies suggested for treatment of Sensory Processing Disorders:
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Sensory Integration Therapy
Occupational Therapy
Sensory Gyms
Intervention strategies suggested for treatment of conduct problems:
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Anger Management Skills Training
Independent Group-Oriented Contingency Management
Interdependent Group-Oriented Contingency Management
Moral Motivation Training
Multimodal Interventions
Multisystemic Therapy
Parent Training
Problem-Solving Training
Social Skills Training
***CONFIDENTIAL***
The following psychological assessment report is intended as a communication between professionals. This
report includes sensitive information that is likely to be misinterpreted by those without the necessary
training. Authorization for use of this report is limited to the examinee and their designated consultants. Any
further use requires the authorization of the examinee or their legal guardian. Use or disclosure outside these
parameters constitutes a violation of HIPPA.
7
CONFIDENTIAL Evaluation- XXXXXXX – Page
8
Recommendations for Parents:
Sensory Processing Disorders
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Give advanced warning prior to hugging or touching your child.
Find alternatives to showing love through physical affection- give a pinky promise,
squeeze their shoulder, etc.
Help your child set physical boundaries with friends and family.
Experiment with different textures in food such as crunchy ice cubes and snacks.
Don’t take your child’s negative behavior personally.
Encourage your child to use the skills he or she is learning in therapy at home.
Actively participate in your child’s treatment and consult with his or her treatment
provider regarding concerns and questions.
Create and maintain a low-stress, safe, and structured home environment to help support
your child’s treatment and overall emotional health.
Respond to unwanted behaviors in a firm, consistent manner.
Always strive to remain calm.
Be genuinely supportive in both your words and actions.
Minimize triggers that you know will cause discomfort for your child. I.e. keep lights
dimmed, minimize loud noises, cut off itchy tags etc.
Autism Spectrum Disorder
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Use a calm, quiet approach when talking to your teen.
Allow teen to have their own space, while ensuring that they don’t isolate altogether.
Limit online activities and encourage face-to-face interactions with people.
Stay on a regular routine. Keep a calendar in your teen’s room and give advance notice
for any change in regular routine.
When talking to your teen engage in an activity, such as walking through the park or go
for a drive, rather than sitting looking at them.
Use lots of subtle and genuine praise. Teens with autism generally have low self-esteem
and need more genuine praise then neuro-typical children. But remember that many
autistic teens dislike being singled-out in front of others and praised.
Attention/Hyperactivity
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Follow a routine. Establish rituals around meals, homework, bedtime etc.
Break tasks into manageable pieces by using a wall calendar or color-coded chore chart.
Focus on the positive and praise your child often.
Help your child develop social skills such as maintaining eye contact and not interrupting
others during a conversation.
Set appropriate boundaries and enforce consequences for breaking these boundaries.
***CONFIDENTIAL***
The following psychological assessment report is intended as a communication between professionals. This
report includes sensitive information that is likely to be misinterpreted by those without the necessary
training. Authorization for use of this report is limited to the examinee and their designated consultants. Any
further use requires the authorization of the examinee or their legal guardian. Use or disclosure outside these
parameters constitutes a violation of HIPPA.
CONFIDENTIAL Evaluation- XXXXXXX – Page
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9
Limit distractions such as TV, video games, computer time and encourage child to
engage in active play.
Regulate sleep patterns. Eliminate stimulates such as sugar and caffeine 1-2 hours prior to
bedtime and establish a bedtime ritual.
Schedule breaks for yourself when feeling frustrated and/or overwhelmed. Go for a walk,
spend time at the gym, or take a relaxing bath.
Anxiety
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Be available and willing to listen to your child.
Model healthy coping strategies for worry and anxiety.
Try not to encourage needy or avoidant behavior in your child.
Help your child learn to manage time and prioritize obligations.
Encourage your child to face fears to help foster independence and self-confidence.
Do not judge, ridicule, or criticize what your child is experiencing.
Avoid nagging or lecturing your child. Talk to your child in an open, honest, and
respectful manner.
 Encourage your child to participate in calming activities such as yoga, mindfulness, and
meditation.
Depression
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Spend quality time with your child doing things he/she enjoys.
Help your child feel connected by encouraging him to join a club at school or attend
activities, give them ideas on attending social events, encourage play dates and
sleepovers at your house, organize family gatherings.
 Encourage open and honest conversations and listen to what your child has to say.
 Try not to be dismissive about your child’s inner struggles, even if the problem seems
small to you.
Poor Conduct
 Set firm boundaries and rules at home but avoid getting into power-struggles with your
child.
 Make yourself available (and willing) to listen and let your child know you’re there for
him or her
 Be fair, reasonable, and consistent with rules you set and the ways in which you enforce
them.
 Communicate rules and consequences clearly.
 Be patient and understanding. It will take time for your child to break old patterns of
behavior and develop a more positive attitude.
 Don’t take your child’s negative behavior personally.
 Encourage your child to use the skills he or she is learning in therapy at home.
 Create and maintain a low-stress, safe, and structured home environment to help support
your child’s treatment and overall emotional health.
 Respond to unwanted behaviors in a firm, consistent manner.
 Be genuinely supportive in both your words and actions.
***CONFIDENTIAL***
The following psychological assessment report is intended as a communication between professionals. This
report includes sensitive information that is likely to be misinterpreted by those without the necessary
training. Authorization for use of this report is limited to the examinee and their designated consultants. Any
further use requires the authorization of the examinee or their legal guardian. Use or disclosure outside these
parameters constitutes a violation of HIPPA.
CONFIDENTIAL Evaluation- XXXXXXX – Page 10
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Frequently check-in with your child to see how he or she is doing, whether treatment is
helping, and to see if there is anything you can do that would be helpful.
***CONFIDENTIAL***
The following psychological assessment report is intended as a communication between professionals. This
report includes sensitive information that is likely to be misinterpreted by those without the necessary
training. Authorization for use of this report is limited to the examinee and their designated consultants. Any
further use requires the authorization of the examinee or their legal guardian. Use or disclosure outside these
parameters constitutes a violation of HIPPA.