Sample of Psychological Report

Psychological Report
I. Identifying Information:
Name : EM
Age : 36 years old
Civil Status : Married
Gender : Female
Birthdate : August 25, 1983
Birthplace : Tanay, Rizal
Educational Attainment : Grade 1
Pavilion/Area : Women and Child Protection Unit
Case : VAWC – Rape (June 23, 2019)
II. Assessment Tools:

Clinical Interview
Bender Visual Motor Gestalt Test
Draw-A-Person Test
Sach’s Sentence Completion Test
Wechsler Adult Intelligence Scale – Revised
All tests were administered on October 23, 2019
III. Case Background

The client stated that on June 23, 2019, around 6 o’clock in the morning while she
was on her way to buy food, she was pulled by a man in the creek near the back of their
house. According to her, there are no other people who witnessed what happened that
day. She was allegedly sexually harassed by CR who’s at that time seemed not on his
right mind. She was kissed all over her body and forced to open her mouth and suck
his private part. After the incident she was told to go home and not to tell anyone about
what happened or else it could happen again. One week had passed when she told her
husband about what happened. They immediately go to their barangay and filed
complain against Mr. CR. They are both asked to have a face-to-face meeting but Mr.
CR did not showed up for two meetings. On the third meeting Mr. CR showed up and
they are told to query the case. Mr. E didn’t agree and they seek help to police station
in Rizal wherein they are asked for medical record that could affirm that EM was raped.
EM was accompanied by her husband Mr. E in NCMH. Their last visits happened
on August 27. She was referred by the DSWD in Binangonan Rizal Municipal Office.
The client did not have any history of mental illness, hence she was aware that her
mental capability was not inclined with her age, and the reason of their visit to WCPU
is for psychological evaluation to be use in filing case for Rape against CR.
The client said that she does not drink nor using drugs and vices.
According to EM she regularly sleep around 6 o’clock in the afternoon till 2 o’clock
in the morning. She has a hard time sleeping again after waking up early in the morning.
She also had bad dreams about a man whose eyes are blast out. Her appetite is normal
and she ate three times a day.
She hear male voice calling her that she think she is the only one who can hear
(hallucination) and she also can see a girl without face in the back of their house which
she think she is the only one who can see (delusions).
The client were not prescribed with any kind of medications. She has not even taken
any psychological drugs.
IV. Testing Behavior

The client arrived at the facility around 10:30am, she wore black shirt with polka
dots design, denim pants, red slippers, and silver watch. She had her long black hair
tied, pair of brown eyes, and freckles in her face. She has a normal built, and medium
skin complexion. Her front teeth were absent. She has an approximately height of 5’2.
Elizabeth was participative and her voice was normal and she patiently stay to finish
her testing. She sometimes feel shy answering and cover it with laughing.
She stated that she was happy. Her affect shows that she is happy and ready for the
assessment.
The client was oriented to time, place, and person.
When she was asked for the first time about her age she answered “25”, on the
second time around she answered unsurely “27”, and upon the interview with her
husband it came out that she is already 36 years old. She also did not know how to
write and read making it difficult for her to write her name on the paper. She also write
her age and the date in reverse. She was listening carefully on the instructions and
focused on drawing. She laughed when she did not know how to draw the figures and
making circles instead of imitating the right angles. She also pouted her lips and looks
directly to the examiner. There are times she shook her head and laughed when she did
not understand the question. She has hard time in completing some of the performance
subtests.
V. Test Evaluation:
WAIS – R Verbal Scale - 59
Performance Scale - 60
Full Scale - 56
Classification - Mild Mental Retardation
The result shows that her common sense reasoning was poor. In addition, her fund
of general knowledge, wealth of early educational attainment, visual motor speed,
attention-concentration span, ability to see relationships between things and ideas,
ability of analyzed abstract figures/reasoning, numerical reasoning, ability to
comprehend and evaluate total situation, visual memory, and her ability to perceive the
relationship of parts to whole were impaired.
The patient is emotionally disturbed and experiences ongoing emotional state
defined by negative reaction and feelings. She has possible catatonia that is marked by
a significant decrease in her reactivity in the environment. The patient has inability to
not speak on her thought and her personality reverts to an earlier stage of development,
adopting more childish mannerisms. She expresses dissatisfaction and uncertainty
about herself and her effectiveness as an individual. She has possible auditory
hallucination that causes her impulsive reaction. Lastly, she has difficulties in creating
a deep, strong, and close association with other person and could possibly shows
antisocial behavior.
The patient expresses positive feelings towards her family unit despite knowing
that her family does not recognize her as a mature person but has no difficulty in
relating with them. She also expresses good mutual relationship with the people
surrounding her. She also recognized her rights and opinions.
The patient used reaction-formation to cover up her feelings of anxiety, inability to
deal with a situation in her life, and inability to take an effective action through her
childish actions.
VI. Overall Impression and Recommendation

Based on the results of the assessment and interviews, EM IQ level falls under Mild
Mental Retardation. The patient has difficulty in maintaining her mental capability
inclined with her age. EM should undergo supportive psychotherapeutic intervention
to address and improve the client social functioning and coping skills.
BERSAMIN, ROCHELLE JOYCE O.
St. Dominic College of Asia
Date: January 31, 2019

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Psychological Report

II. Assessment Tools:

III. Case Background

IV. Testing Behavior

VI. Overall Impression and Recommendation

BERSAMIN, ROCHELLE JOYCE O.

St. Dominic College of Asia

Date: January 31, 2019

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