COGNITIVE EVALUATION C ONF I DE NTIAL Client: Date of Birth: Date of admission: Date(s) of evaluation: Evaluated by: Referred by:

Referral question: Mr./Ms. Smith is a (age, ethnicity, marital status, handedness, gender) with ..years of education. Self reported complaints include My understanding is that s/he needs to be evaluated to better understand the nature and extent of his/her difficulties to assist with ..

Guidelines: At a minimum, this section should include three sentences including demographic/orienting information, list of complaints, and what questions need to be answered. The questions that need to be answered should be used to provide focus for the rest of the report and should each be answered in some depth in the Interpretation/Impressions section and then quite concisely in the Summary. Be sure to make the referral question section concise. A frequent difficulty is that students try to make it too long by including too much history.
Evaluation procedures: Clinical interview, Neuropsychological Symptom Checklist, Wechsler Adult Intelligence Scale-III (WAIS-III), Wechsler Memory Scale-III (WMS-III), Bender Visual Motor Gestalt Test (Bender), Beck Depression Inventory-II (BDI-II). Total evaluation time was hours.

Guidelines: This section is usually just a listing of what evaluation procedures were used. It should include the full name of the test with the abbreviation in parentheses next to it. It can then be referred to by its abbreviated name later in the report. Sometimes it might be necessary to include the date and length of time it took for each test. However, this is usually unnecessary information and merely clutters up the report.
Behavioral observations: Mr./Ms Smith arrived (on time/late) to his appointment and was oriented to (person, time, place, reason for assessment). Given the above behavioral observations, I believe the results are an (accurate/not accurate) assessment of his/her current level of functioning.

Guidelines: This should be a concise description of relevant behavioral observations. It can sometimes include a summary of the clients mental status. The most frequent student error with this section is to add far too much detail. It should usually be one paragraph in length. This means including only those aspects of behavior that are most relevant.
Background: Personal/Social: Academic/Vocational: Medical: Psychiatric:

Guidelines: Be sure to organize background information into clear domains (i.e. personal/social) as listed above. When describing symptoms, be sure to include a full description of the nature of symptoms (i.e. if depressed include such symptoms as poor appetite, sleep disturbance, anhedonia, psychomotor slowing, suicidal ideation, critical self statements etc.) and their onset, duration, severity, and frequency (i.e. symptoms began 8 months ago, have occurred 2-3 times a week, are moderately severe). If you are going to provide an actual DSM-IV diagnosis, you should make sure the relevant information to make the diagnosis is included in your background information section.
Interpretation and Impressions: General level of intellectual function: Overall level of functioning was in the range or .. percentile when compared with his/her age-related peers. Given the pattern of test scores and premorbid level of functioning, I believe this represents a significant decrease in his/her abilities. Verbal skills: Perceptual organizational (nonverbal) abilities: Attention and concentration (working memory): Speed of information processing: The speed by which the client processes information is in the Memory: Overall memory was in the Psychiatric:

Guidelines: This is the hardest but also the most important section. One major challenge is to not only provide the data (i.e. Full Scale IQ was 112 which places him in the High Average range) but also make it relevant to the persons life and also answer the referral question. There are many strategies for doing this, many of which are included in

Groth-Marnats (2003) Handbook of Psychological Assessment (4th edition). Important ones are to include examples (i.e. For example, they were only able to repeat a maximum of four numbers that were read to them.). Another one is to translate the scores into the clients every day life (i.e. This means they would have a difficult time remembering instructions, telephone numbers, or details from social interactions.). An essential element is that your interpretations should be integrated. This means they should not be test oriented (avoid such red flag statements as test results indicate, a score of 78 on scale 4 indicates or people with these types of profiles).
Summary:

Guidelines: The summary should briefly review the major findings of your report. A frequent mistake students make is to write a summary that is too long. Ordinarily it should be one paragraph in length. The summary is also the place to concisely answer each of the referral questions. Sometimes this can be done in bulleted form and be linked directly to each of the referral questions.
Recommendations: Given the above findings, the following recommendations seem appropriate:

Guideline: A few sample recommendations relevant for a rehabilitation hospital are the following;
1. Mr./Ms. Smith will require 24-hour supervision upon discharge. 2. Cognitive rehabilitation should focus on: a. External memory compensation strategies including a memory diary, notes on a whiteboard, and alarms (i.e. for medications, appointments) b. Use of environmental cues c. Organize communication to ensure understanding (remove environmental distractions, simplify instructions, repeat information, allow extra processing time) d. Have patient write notes before speaking e. Alter patients environment (remove hazards, remove clutter, use alarms, make important features more salient) 3. Patient and family should receive ongoing education about the effects of brain injury and associated cognitive deficiencies may have on his functional status (occupational, social, relational, emotional, behavioral) as well as methods for adapting to such deficiencies 4. The patient and family would benefit from learning about resources for brain injury survivors and their family (Brain Injury Association; www.biausa.org)

Guidelines: The recommendations should be clear, specific, and achievable. Recommendations for a forensic, psychiatric, or educational setting will be somewhat different. You can delete or expand the above recommendations if not appropriate or add other ones.
Signature:

Name of Examiner: Qualifications/title: Date: cc: