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Identifying Information
Basic demographic data of the client such as name, age, gender, date of birth, education, occupation, and contact details—used to identify the report.
Source of Referral
Explains who referred the client and why, summarizing the main reason for assessment or evaluation.
Background Information
Summarizes relevant personal, medical, educational, and social history that provides context for test results and behavior.
Tests and Procedures Used (Measures Administered)
Lists all assessment tools, interviews, and techniques used during evaluation, including test names, editions, and brief purposes.
Behavioral Observations
Describes how the client behaved during testing or interviews—appearance, attitude, motivation, speech, and interaction style.
Test Results and Interpretation
Presents and explains scores from tests, interpreting what they mean about the client’s functioning, strengths, and weaknesses.
Summary and Recommendations
Consolidates major findings and provides practical, clear, and actionable recommendations for intervention or further evaluation.
Consent and Assent
Ethical requirement ensuring the client (or guardian) agrees to assessment
Mental Status Examination (MSE)
A structured observation that assesses a client’s appearance, mood, speech, thought, cognition, and orientation to evaluate psychological functioning.
Interview
A method of gathering information through structured, unstructured, or semi-structured conversation between assessor and client.
Structured Interview
Interview type where identical questions are asked in a fixed order to increase reliability and reduce bias.
Unstructured Interview
Flexible and conversational interview type that allows deeper exploration but lower reliability.
Semi-Structured Interview
Combines fixed questions with open follow-ups for both consistency and flexibility.
Behavioral Observation
Systematic recording of the client’s behaviors, reactions, and interactions in testing or natural settings.
Social Facilitation
Phenomenon where a person’s performance or behavior changes (often improves) in the presence of others.
Carkhuff Levels of Responding
A system rating interviewer empathy from low to high accuracy—Level 3 reflects understanding equivalent to the client’s message.
Probing
Follow-up questioning technique used to clarify or elaborate without sounding judgmental or intrusive.
Empathy Response
Reflecting a client’s feelings and meanings to show understanding and build rapport.
Restatement or Paraphrasing
Rephrasing the client’s message to confirm understanding and encourage elaboration.
Clarification
Asking for more detail or precision when a client’s statement is vague or ambiguous.
Summarization
Briefly reviewing main ideas or emotions shared to ensure mutual understanding and transition to a new topic.
Reflection of Feeling
Repeating or paraphrasing the emotional content of what the client says to show empathy.
Confrontation
Pointing out discrepancies between what a client says and does, done respectfully to increase self-awareness.
Verbatim Playback
Repeating the client’s exact words to prompt deeper thought or clarification.
Interviewer Bias
Tendency for an interviewer’s expectations, attitudes, or personal beliefs to distort data collection or interpretation.
Halo Effect
Bias where one positive or negative trait influences the overall impression of a person.
Standoutishness
Bias when one unique characteristic (e.g., dress, speech) overshadows other information.
Contrast Effect
Bias that occurs when an interviewer’s judgment of one person is influenced by comparison with another.
Inter-Interviewer Reliability
Degree of agreement between different interviewers evaluating the same individual.
Wechsler’s Definition of Intelligence
“The global ability to act purposefully, think rationally, and deal effectively with the environment.”
Spearman’s g Factor
The general intelligence factor that underlies performance across various cognitive tasks.
Fluid Intelligence
Ability to reason, solve new problems, and adapt to unfamiliar situations independent of prior knowledge.
Crystallized Intelligence
Knowledge and skills gained from experience, education, and culture used to solve familiar problems.
Piaget’s Accommodation
Adjusting existing mental schemas to incorporate new experiences or information.
Positive Manifold
Phenomenon where individuals who perform well on one cognitive task tend to perform well on others.
Basal Level (in Stanford-Binet)
Starting point where the test-taker answers a set number of items correctly, establishing their base ability level.
Ceiling Level (in Stanford-Binet)
The level where the test-taker consistently fails items, marking the upper limit of their performance.
Deviation IQ
Type of scoring in Wechsler tests comparing an individual’s performance to the population mean rather than mental age.
Individual Test
Administered to one person at a time, allowing detailed observation and adaptive testing.
Group Test
Administered to many individuals simultaneously, useful for screening large numbers efficiently.
Routing Test (SB5)
A brief initial test used to determine the appropriate starting point for further subtests based on ability.
Effective Interviewing Techniques
Skills and strategies used to elicit accurate, meaningful information—includes active listening, empathy, and neutrality.
Active Listening
Fully concentrating on what the client says and observing nonverbal cues to ensure accurate understanding.
Avoiding “Why” Questions
Technique to prevent defensive reactions by rephrasing questions in a nonjudgmental way.
Open-Ended Questions
Questions that allow clients to express thoughts and feelings freely rather than giving yes/no answers.
Closed-Ended Questions
Questions that require brief, specific responses, useful for confirming facts or details.
Neutrality
Maintaining a nonjudgmental stance so the client feels safe to disclose information honestly.
Rapport Building
Creating a trusting and comfortable atmosphere through warmth, respect, and empathy.
Cultural Sensitivity
Recognizing and respecting the client’s cultural background, beliefs, and communication styles during assessment.
Confidentiality
Ethical responsibility to protect client information and disclose it only with consent or for legal reasons.