PSYCHOLOGICAL REPORT
Presented to Mr. Wilbert Desuyo
Psychological Assessment Instructor
Kolehiyo ng Lungsod ng Dasmariñas
City of Dasmariñas, Cavite, Philippines
In Partial Fulfillment
of the Requirements for the Course of
PSYCHOLOGICAL ASSESSMENT
Submitted by:
EA, MARIA JIESELLE E.
DECEMBER 12, 2024
TABLE OF CONTENTS
DEMOGRAPHIC DATA……………………………………………………………………….1
REASON OF REFERRAL……………………………………………………………………...2
ASSESSMENT TOOLS USED…………………………………………………………………3
BEHAVIORAL OBSERVATION………………………………………………………………4
CASE BACKGROUND…………………………………………………………………………5
STRENGTHS, INTEREST AND PLANS………………………………………………………6
ASSESSMENT…………………………………………………………………………………..7
Cognitive/intellectual functioning……………………………………………………………….a
Emotional - Social Functioning………………………………………………………………….b
Personality.……………………………………………………………………………………….c
Learning Style…………………………………………………………………………………...d
Formulation………………………………………………………………………………………e
Needs Identified………………………………………………………………………………….f
APPENDICES…………………………………………………………………………………...8
I. DEMOGRAPHIC DATA
Name: He/She
Birth Date: March 23, 2004
Birthplace: Dasmarinas, Cavite
Age: 20 years old
Address: Dasmarinas, Cavite
Civil Status: Single
Sex: Female
Religion: Iglesia ni Cristo
Date of Assessment: Dec. 11, 2024
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II. REASON OF REFERRAL
The client was referred for psychological assessment to evaluate his/her psychological, social,
and cognitive functioning and learning style important for identifying his/her strengths and
weaknesses as a student.
He/She was also referred as a practice for the assessor to make psychological report as
preparation for his/her clinical internship.
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III. ASSESSMENT TOOLS USED
MMSE Mental health State Examination October 07, 2024
LSI Learning Styles Inventory December 07, 2024
PHQ-9 Patient health Questionnaire November 16, 2024
DAT Differential Aptitude Tests November 23, 2024
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IV. BEHAVIORAL OBSERVATION
This section outlines the behavioral observations made during the assessment period,
emphasizing the contextual factors and emotional dynamics that may influence the individual’s
psychological well-being.
The Patient Health Questionnaire-9 (PHQ-9) is a widely used tool for assessing the severity
of depression. It consists of nine items that correspond to the diagnostic criteria for major
depressive disorder as outlined in the DSM-IV. Each item is scored on a scale from 0 (not at all)
to 3 (nearly every day), allowing for a maximum score of 27.
The PHQ-9 serves multiple functions, including screening for depression, aiding in diagnosis,
and monitoring treatment response over time. It is particularly effective in primary care settings
and has been validated across diverse populations.
The client depression severity in PHQ-9 test is Severe depression, then I gave her another test
The MMSE Mini - Mental state examination also known as the Folstein test, is a widely
utilized tool for assessing cognitive function, particularly in the context of dementia screening.
The test consists of a 30-point questionnaire that evaluates various cognitive domains, including
orientation, registration, attention and calculation, recall, language, and the ability to follow simple
commands.
During the clinical interview conducted in the classroom on December 11, 2024, The client
presented with noticeable signs of anxiety throughout the duration of the observation. As the
session began, the client appeared visibly tense with their body language reflecting discomfort.
She sat with her arms crossed tightly and avoided eye contact, which suggested feelings of
vulnerability and apprehension.
As we discussed various topics related to her daily life and stressors, the client frequently
fidgeted with her hands, playing with a pen and tapping it against the floor. This behavior seemed
to be a coping mechanism for managing her anxiety, As she often shifted in her seat and
occasionally glanced at her wrist watch, indicating desire to escape the conversation or
preoccupation with time.
When I asked about open-ended questions about her feelings, the client hesitated before
responding, often taking deep breaths and pausing for several seconds. Her speech was somewhat
fragmented, punctuated by frequent “ums” and “uhs”, which further highlighted her struggle to
articulate their thoughts under pressure. At times, they expressed concerns about being judged or
misunderstood, which seemed to exacerbate her anxiety.
In moments of discussing particularly stressful experiences, the client’s emotional state
became more pronounced. She displayed signs of distress, such as biting her lip and clenching her
fists. Her voice trembled slightly when recounting situations that triggered her anxiety.
Despite these challenges, the client demonstrated a willingness to engage in therapeutic
dialogue. She expressed a desire to learn coping strategies to manage her anxiety more
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effectively. By the end of the session, there was a slight shift in her emotions; she appeared
more relaxed when discussing potential solutions and expressed gratitude for the opportunity to
share her experience.
This observation highlights the client’s struggle with anxiety manifested through physical
tension, avoidance behaviors, and difficulty articulating thoughts. However, Her openness to
discussing these issues suggests a readiness for therapeutic intervention aimed at developing
healthier coping mechanisms.
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V. CASE BACKGROUND
The client describes experiencing persistent anxiety, particularly in situations that involve
performance or social interaction. She report a constant fear of failure and tendency to overthink
her actions and decisions. This anxiety has led to avoidance behaviors, including reluctance to
engage in social activities and difficulties at work. Additionally, the client has expressed feelings
of sadness and frustration related to her perceived inability to meet both her own expectations and
those imposed by others.
In recent months, the clients has noticed an increase in physical symptoms associated with
anxiety, such as restlessness, muscle tension, and sleep disturbances. The client completed the
Patient health questionnaire-9 (PHQ-9), which indicated moderate levels of depressive symptoms
and anxiety.
The client is a 20 years old female who has been referred for psychological evaluation
following a traumatic event that has significantly impacted her mental health. The client
experienced harassing in public place, while occurred on August 3, 2022. Since this incident, the
client has reported a range of distressing symptoms that suggest the development of post-traumatic
stress disorder (PTSD).
The client grew up in a household characterized by strict rules and high expectations. Her
parents emphasized discipline, achievement, and conformity. Often expressing disappointment
when the client did not meet their standards. This environment fostered a sense of pressure that
has persisted into adulthood, leading to feelings of inadequacy and self-doubt.
As a child, the client was often praised for academic achievements but criticized for perceived
failures. This pattern created an internal narrative that equated self-worth with performance. The
client recalls feeling anxious about making mistakes or disappointing her parents, which led to
perfectionist tendencies that continue affect her life today.
The client has a limited support network. She have friends who are sympathetic to her struggles
but often feel disconnected due to her anxiety and perfectionism. The client has begun seeking
professional help as part of an effort to address these issues and develop healthier coping strategies.
The client completed her secondary education with commendable grades and was accepted
into Kolehiyo lungsod ng dasmarinas, where she are now in her 3 rd year of study. Throughout her
academic journey, she have demonstrated a strong commitment to learning and personal growth.
However, The demands of the program have led to heightened levels of anxiety, particularly as
they navigate complex coursework and clinical placements.
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VI. STRENGTHS, INTEREST AND PLANS
STRENGTHS
One of the most notable strengths of my client is her resilience. Despite facing significant
stressors, including family issues, pressure in studying. The client has consistently show an ability
to adapt and cope with adversity. My client shared her instances where she successfully managed
difficult situations by employing problem-solving technique and seeking support from friends and
family. This ability to bounce back from setbacks reflects a strong inner fortitude that can be
harnessed in therapy.
INTEREST
During the clinical interview, My client expressed a variety of interests that reflect her
personality and coping mechanisms. The client described a deep passion for art, particularly
painting and drawing, which she have engaged in since childhood. She also shared that creating
art serves as a therapeutic outlet for her allowing her to express emotions that are often difficult to
articulate verbally. The client noted, “When I paint, I feel like I can communicate what I’m going
through without having to say a word.” This creative process not only provides her with joy but
also helps alleviate feelings of anxiety and stress.
The client enjoys outdoor activities, particularly hiking and nature walks. She mentioned that
spending time in nature helps her feel grounded and connected to the world around her. “Being
outside clears my mind,” the client stated, highlighting how these experiences contribute positively
to their mental health. She often seek out local trails and parks, emphasizing the importance of
physical activity in managing her mood.
The client also expressed an interest in reading, particularly fiction and self-help books. She
enjoy immersing herself in different narratives as a means of escape and reflection. The client
shared that she appreciate stories that explore complex emotional themes, as she find comfort in
knowing she’s not alone in her struggles. This interest in literature aligns with her desire for
personal growth and understanding.
The client values meaningful connections with friends and family. Although she have
experienced some social anxiety, She expressed a strong desire to cultivate deeper relationships.
She mentioned participating in a local book club as a way to engage with others who share similar
interests while also challenging herself to step outside their comfort zone.
Overall, The client interests in art, nature, literature, and social connection reveal a
multifaceted personality that seeks both creative expression and meaningful engagement with the
world. These interests not only provide insight into her coping strategies but also serve as potential
focal points for therapeutic exploration.
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PLANS
During the clinical interview, The client articulated a clear vision for her future,emphasizing
personal growth, career aspirations, and the importance of mental well-being. The client expressed
a strong desire to overcome the anxiety that has been a significant barrier to achieving her goals.
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VII. ASSESSMENT
A. Cognitive/intellectual Functioning
At the outset of the assessment, The client demonstrated good orientation to person, place,
and time. They accurately identified their name and current location as well as the date and
season. This indicates intact orientation skills, which are critical for daily functioning.
The next section of the MMSE assessed attention and calculation abilities. The client was asked
to perform simple arithmetic tasks, such as counting backward from 100 by sevens. She was able
to complete this task with some hesitation but ultimately demonstrated adequate concentration and
attention span. This suggests that while they may experience slight difficulties under pressure,
their cognitive processing remains functional.
Evaluating memory through registration and recall tasks. The client was instructed to remember
three words presented at the beginning of the assessment. Upon prompting later in the session, the
client successfully recalled two out of three words after a brief distraction. This indicates mild
short-term memory impairment but suggests that their memory function is relatively preserved
overall.
In assessing language skills, The client was asked to name common objects presented by the
assessor and follow simple verbal commands. The client exhibited strong verbal skills, accurately
naming all objects and demonstrating an ability to follow multi-step instructions without difficulty.
This reflects intact language functioning and comprehension abilities.
The MMSE evaluated visualization skills through a drawing task where the client was asked to
copy a simple geometric figure. The client was able to replicate the figure with reasonable
accuracy, indicating preserved visualization processing abilities.
Overall, The client performance on the MMSE suggests that their cognitive intellectual
functioning is within normal limits with some minor areas of concern regarding short-term
memory recall under stress. The total score from the MMSE was 29 placing them in the range
indicative of Severe depression. These findings will be instrumental in guiding further therapeutic
interventions and monitoring cognitive changes over time. Recommendations include continued
engagement in cognitive exercises and strategies to enhance memory retention and stress
management techniques.
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B. Emotional - social functioning
The client reported experiencing a range of depressive symptoms, which were captured through
the nine items of the PHQ-9. Each item assesses different aspects of depression, including mood,
interest in activities, sleep patterns, energy levels, appetite changes, feelings of worthlessness or
guilt, concentration difficulties, psycho motor changes, and thoughts of self-harm .Upon scoring
the PHQ-9, The client achieved a total score of 24, indicating severe depression. This score reflects
significant challenges in emotional regulation and social functioning.
The assessment revealed that the client has been experiencing persistent feelings of sadness and
hopelessness. They indicated that they often feel down or depressed "more than half the days,"
which has led to a diminished interest in activities that once brought them joy. This anhedonia is
particularly concerning as it affects their motivation to engage socially and pursue hobbies.
The client reported difficulties with concentration and decision-making. She expressed
frustration over their inability to focus on tasks at work and at home, which has further
compounded their feelings of inadequacy and self-doubt. These emotional struggles have created
a cycle where negative thoughts exacerbate depressive symptoms, leading to increased isolation.
In terms of social functioning, the client noted significant avoidance of social situations due to
anxiety about being judged or misunderstood. She described feeling overwhelmed in group
settings and often choose to decline invitations from friends and family. This withdrawal has
resulted in feelings of loneliness and disconnection from their support [Link] client also
reported that her depressive symptoms have impacted her relationships with loved ones. She
expressed concern that she have become distant from friends who once provided emotional
support. The fear of burdening others with her struggles has led them to isolate herself further.
The results from the PHQ-9 highlight critical areas of concern regarding the client emotional
and social functioning. The significant depressive symptoms identified through this assessment
suggest a need for targeted therapeutic interventions aimed at improving emotional regulation and
enhancing social engagement.
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C. Personality
D. Learning Style
One tool that has gained prominence in this area is the Learning Styles Inventory (LSI), which
helps individuals identify their unique ways of processing information and engaging with the
learning material. The LSI is rooted in the belief that each person has a preferred style of learning
that can significantly influence their educational experience.
The client described how they often find it easier to grasp complex concepts when presented
with visual representations. She enjoy using charts, graphs, and infographics to break down
information into digestible pieces. For instance, when studying for exams, the client prefers to
create colorful mind maps that visually organize key ideas and relationships between topics. This
method not only aids in memory retention but also makes the learning process more engaging and
enjoyable.
Despite their strengths as a visual learner, The client acknowledged some challenges. She often
struggle with purely auditory instructions or lectures without accompanying visuals. In instances
where information is conveyed verbally without visual support, the client finds it difficult to retain
details and may feel overwhelmed by the amount of information presented.
In summary, The client assessment reveals a clear preference for visual learning strategies that
enhance their understanding and retention of information. By leveraging her strengths in this area
while addressing challenges associated with auditory learning environments, the client can create
a more effective and fulfilling educational experience. Her commitment to advocating for her
learning needs will empower them to navigate academic challenges successfully.
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E. Formulation
During the recent client interview and observation, I gained valuable insights into my client’s
emotional and cognitive functioning, as well as her unique challenges and strengths. This
assessment provided a comprehensive view of her experiences, allowing me to better understand
her needs and how to support her moving forward.
One of the most striking realizations was the depth of My client’s emotional struggles.
Throughout the interview, she articulated feelings of anxiety and sadness that have been pervasive
in her daily life. It became clear that these emotions are not just fleeting; She significantly impact
the client’s ability to engage in social situations and perform at school. The client expressed a
sense of hopelessness regarding her circumstances, which resonated deeply during our
conversation. This insight highlighted the urgency for targeted interventions that address these
emotional challenges.
As we discussed coping strategies, I observed my client has developed some adaptive
mechanisms but also relies on avoidance behavior, She mentioned using mindfulness techniques
to manage anxiety, which indicates a proactive approach to their mental health. However, it was
evident that they often resort to isolating themselves when feeling overwhelmed, choosing to
withdraw from social interactions rather than seeking support. This pattern of avoidance is a
significant barrier to her progress and underscores the need for therapy focused on building social
skills and confidence.
Despite these challenges, I was inspired by My client’s resilience and willingness to engage in
the therapeutic process. She expressed a desire to improve her situation and showed openness to
exploring new coping strategies. This motivation is a significant strength that can be harnessed in
therapy. The client’s ability to articulate her feelings and recognize patterns in her behaviour
reflects a level of insight that will facilitate meaningful progress in treatment.
These realizations from the interview and observation will guide my approach in working with
the my client. It is clear that addressing her emotional distress through evidence-based therapeutic
techniques will be essential. Additionally, incorporating strategies to enhance social interactions
and reduce avoidance behaviors will be vital for her overall well-being.
This assessment has deepened my understanding of This client experiences and highlighted both
the challenges she face and the strengths they possess. By fostering an environment of support and
understanding.
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F. Needs identified
During the assessment, The client completed the Patient Health Questionnaire 9 (PHQ-9),
Which indicated moderate depressive symptoms. The insights from the Learning Styles Inventory
(LSI) revealed a strong visual learning preference. These findings provide a foundational
understanding of the client’s emotional state and learning style; however, they do not fully capture
the complexities of her experiences.
Comprehensive Diagnostic Assessment Given the moderate severity of the depressive
symptoms reported, it would be prudent to conduct a more comprehensive diagnostic assessment.
This could include standardized instruments such as the Beck Depression Inventory (BDI) or the
Generalized Anxiety Disorder 7-item scale (GAD-7) to evaluate anxiety levels in conjunction with
depression. A thorough assessment will help clarify the specific nature of the client’s mental health
concerns and guide treatment planning.
While the initial assessment of the client has yielded important information regarding her
emotional well-being and learning preferences, further testing and interviews are necessary to gain
a comprehensive understanding of the mental health landscape. By utilizing additional diagnostic
tools and conducting in depth interviews, We can better identify co-occurring conditions and tailor
interventions that address both emotional challenges and learning needs. This personal life more
effectively.
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VIII. RECOMMENDATIONS
Following a thorough clinical assessment, it is clear that the client is experiencing significant
depressive symptoms, as indicated by her responses on the Patient Health Questionnaire-9 (PHQ-
9). In light of these findings, a comprehensive plan has been developed to support her mental health
journey and enhance her overall well-being.
To address the challenges she faces, it is highly recommended that the client engage in cognitive
behavioral therapy (CBT). This therapeutic approach has proven effective for individuals dealing
with depression, as it focuses on identifying and challenging negative thought patterns. Regular
weekly sessions will provide her with a consistent support system, allowing for ongoing
monitoring of her progress and adjustments to her treatment as needed.
Given the severity of her symptoms, a consultation with a psychiatrist is also advised. This
evaluation will explore the potential benefits of medication, such as antidepressants, which may
be appropriate if her symptoms significantly impair her daily functioning or do not improve with
therapy alone. The goal is to ensure that the client has access to all available resources for
managing her mental health.
In addition to therapy and medication, connecting with supportive resources can be invaluable
for the client. Participating in local or online support groups for individuals experiencing
depression can provide her with a sense of community and understanding. Sharing experiences
with others who face similar challenges can help alleviate feelings of isolation. Furthermore,
access to educational materials about depression and coping strategies will empower her to take
an active role in her recovery.
Encouraging the client to incorporate physical activity into her daily routine is another essential
recommendation. Regular exercise whether through walking, yoga, or dancing can significantly
enhance mood by releasing endorphins. Additionally, consulting with a nutritionist to develop a
balanced diet will support her physical health and positively impact her energy levels and
emotional state.
SIGNATURE OVER PRINTED NAME
Clinicians
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