Schools, parents, institutions and courts request psychodiagnostic evaluations to provide diagnosis and treatment recommendations based on professional testing and observation. The psychodiagnostic report should answer referral questions as directly as possible and offer a clear summary of the client's status, capabilities, causative factors of reported problems and recommendations.
State the client's name, age, date of evaluation and examiner. Document the reason for referral. This section captures why a professional psychological assessment was requested and the expected outcome recommendation type such as special education placement, diagnosis, need for therapeutic intervention and competence.
Summarize background information on the client. This report section should be broken up into categories of related information such as medical conditions, test, and medications; clinical history, developmental milestones, education, behavior, social situation and family. Each subsection should be presented in chronological order.
Provide client information details extracted from interviews with parents or family members that were part of the evaluation procedure. Include facts and professional impressions.
Report on your observations of the client during testing and interviewing. If evaluating a young child, include data on free-play behavior and interactions with parents or siblings.
List tests used. Because your report may be read by non-professionals, it is helpful to provide a brief description of what each test measures. Report test results. List test and scoring by section, subtest or total score.
Interpret the test results. This critical section of the report can be approached in several ways: you can report the meaning of the results of each test, tie the results to the initial reasons for evaluation, or integrate the results by category such as intellectual ability, competence, interpersonal skills, neuropsychological factors and mental status.
Write a summary and recommendations. For this section, integrate information from all sections of the report into a capsule of your diagnosis using the DSM IV, your conclusions relative to the reason for evaluation, key findings about the client and recommendations.
Acknowledge the confidentiality of the report information on each page. Print the report on letterhead stationery, sign your name and provide your professional credentials including license number and licensing authority.