Integrated Assessment Report for a Patient with Depression and Anxiety

Integrated Assessment Report Outline
Client Name:
Date of Birth:
Date(s) of Evaluation:
Date of Report:
Examiner:
Supervising Psychologist:
* Identifying Information:
TAYLOR SWIFT is a 19-year-old freshman at Folklore University. She is confused about her gender, and she/they pronouns are being confusingly used.
* Reason for Referral:
The client had reported incidences of depression and anxiousness due to her parents. She had a negative feeling towards her father, and though she is a bit close to her mother, she feels that her mother does not trust her. Moreover, the client had reported instances of using drugs and had mentioned trying to commit suicide.
* Assessment Procedures:
List all procedures used for the assessment in order of administration.
* Review of Client’s Medical Records (List source and date of each record reviewed)
* Clinical Interview with Client
* Collateral Interview with Client’s Parents/Physician/Teacher/etc.… (include Name of Interviewee and Date of Interview)
* Mental Status Examination
* Personality Assessment Inventory (NEO PI)
* Thematic Apperception Test (TAT)
* Background Information:
I am an awkward individual. I am critical of my parents. My mother is semi-normal due to her profession as a lawyer. My mother is also confined to her space. She expresses to the therapist her concern about my school. My parents do not believe me when I tell them about school troubles. I have difficulty concentrating. I have always struggled with these issues. I am easily distracted. I have struggled with these issues for as long as I can remember. My parents attempted to divert my attention to another psychologist or psychiatrist. Other symptoms include an inability to sit and complete tasks such as writing papers. I am 19 years old and admit to abusing a variety of substances. When I am around pals, I engage in drug use. I do nothing except smoke. Smoke serves no use for me at the moment. I am now only smoking blunts at night to help me fall asleep. I experience manic moments; I believe I am the most amusing person in the room. I am attempting to become an artist. Birds are cool to me. Depression is awful; all I want to do is lie in bed all day. Have you ever encountered mania? My entire group of pals is still in high school. I have no intention of meeting random strangers. They admitted me to a hospital. Those girls in the inpatient program are insane; all they do is bitch at one another. I constantly consider suicide. I attempted an overdose and awoke. The incident occurred in 2018.
To be clear, I am running on fumes at the moment. My parents have placed everything behind the lock and key. Suicide provides a greater sense of liberation than being with my parents.
All they do is exercise control over me. My parents are constantly in my room, inquiring as to who I am with. I inform them that they must vacate the premises; I evict them. I am unable to relocate due to a lack of funds. If everything goes well in eval, I may be able to move out. I was on Zoloft for a year, and the psychiatrist assumed I was fabricating events. I suffer from asthma. There was a history of sexual trauma; a friend became inebriated and had sex with me. I gave ...