1. A review of the presenting problem. The presenting problem(s) is the reason the individual is seeking treatment or an evaluation. Examples of presenting problems include: difficulty with falling and staying asleep, poor organizational skills, frequently forgetful, depressed or sad most of the day, anxious or restless throughout the day, difficulty letting go of things, etc.
2. A psychological interview. The interview is where the psychologist gets to know the client personally and in-depth. A review of current symptoms, history of symptoms, and development are collected so that an accurate picture of the individual can be made. Questions are asked in the areas of family, social, medical, and work/school.
3. Psychological testing related to the presenting problem. Based on the information obtained in the presenting problem and comprehensive interview, the psychologist will then identify appropriate testing to obtain specific information about problem areas. Psychological tests typically consist of answering specific questions on standardized instruments. The tests selected may measure moods, personality, aptitude, pathology, skill, intelligence or ability.
4. A summary of the results and feedback session. The psychologist then pulls together all the information gained from the interview and testing to create a clinical picture of the client and generate appropriate diagnoses in four areas: identifiable psychiatric disorders, personality disorders, medical conditions which may be affecting mental health, and social/environmental problems. The summary also includes a Global Assessment of Functioning, which assigns a number. This summary is called a multiaxial assessment and is used to complete the recommendations and suggestions.
5. Recommendations and suggestions. The psychologist now creates a list of recommended interventions to address the problems identified in the multiaxial assessment. These recommendations are typically treatment interventions which have been shown through research and practice to effectively work on the problems identified. The psychologist will refer the patient to appropriate resources to obtain the interventions recommended. For example, if the psychologist has diagnosed the individual with bipolar disorder and recommended a medication consultation, he will likely refer the patient to a psychiatrist for medication(s). Sometimes, the psychologist will provide the treatment interventions himself---depending upon his scope of practice (e.g. using cognitive behavioral therapy in treating a client diagnosed with depression/anxiety).
Typically, a comprehensive psychological assessment report will be provided containing the five essential elements. The report may be used for: obtaining necessary services based upon particular diagnoses, collaborating with teachers and schools regarding services needed to address attention/learning concerns (typically called an IEP or 504 plan), for clarity and accuracy when dealing with multiple healthcare professionals (psychologist and a psychiatrist), and for the tracking of symptoms over time.