Mock Mental Health Evaluation
Client: CLIENT A Date of Evaluation: 7/26/09
DOB: 7/05/69 Date of Report: August 3, 2009
Age: 40
PURPOSE FOR EVALUATION: this mental health evaluation was requested by the Texas Department of Family and Protective Services (DFPS) as a part of the requirements for completing an application to adopt.
Client, is a 40-year-old, single, white female who has obtained the degree level of masters in education. She currently is on staff as a professor at Southern Methodist University and lives in the Dallas/Ft. Worth area.
The request for this evaluation was to evaluate the client’s level of emotional/environmental stress, depression, and anxiety as standard procedure in completing an application to adopt a child in the state of Texas.
ASSESSMENT PROCEDURES:
Basic Personality Inventory
Beck Depression Inventory - II
Beck Anxiety Inventory
Clinical Interview
This client participated in 2 hours of testing and a diagnostic interview. Tests were administered and interpreted by Cristyn Rohloff, MA, LPC.
BACKGROUND INFORMATION:
The client, a 40-year-old, single, white female, lives with alone in a home in Dallas, Texas.
Client graduated with her masters in education from Southern Methodist University in May of 1995. She has talked about wanting to adopt a child for about 5 years and 4 years ago begin the research process into what it would entail from her end. Client has never been married and has found the process a bit more difficult than she believes it to be for a married couple. Since graduating with her masters the client has taught at the high school level as an English teacher and nine years ago begin working at the collegiate level as an English professor for first-year students at Southern Methodist University (SMU). The client reports to have many friends and a supportive family circle. She appears to be quite independent and happy with the single life. She reports that she does not feel it necessary to become married in order to raise a child, she feels adequately prepared financially, emotionally, and mentally. Client denies any use of alcohol or drugs (either prescription or street drugs) except for the occasional drink at dinner when out with friends.
Client has a clean background/criminal history along with no reports of any misconduct in her professorship at SMU.
In regards to her emotional/environmental stress factors, it appears to be no more unusual than the standard professional. She appears to handle stress calmly and as reasonably as she knows how. At this stage of life she had hoped to be married so not as to raise a child alone, but her desire to have a child is great and she felt the need to step out and take a chance with the adoption process. Stated minor depressive episodes as a result of all the legalities in trying to adopt as a single parent.
During the testing phase of the session the client appeared somewhat anxious, but overall very cooperative as she understood it to be common procedure for those wanting to adopt within the state.
MENTAL STATUS EXAMINATION:
Results of mental status examination revealed a stable individual with minor depressive disorder working through the process of adoption in addition to other life commitments. She did not appear to have difficulty staying focused during the session. The client was appropriately dressed and groomed. Orientation was intact for person, time and place. Eye contact was appropriate and rapport was easily established. There was no abnormality of gait, posture or deportment. Speech functions were appropriate for rate, volume, and fluency. Vocabulary and grammar skills were suggestive of intellectual functioning within the above average range.
Client reports she has had no disturbance in her normal sleeping pattern. Appetite has remained normalized and reports no other disturbances in day-to-day functioning. She appears to be popular amongst her students at SMU and within her community of friends. She reports to be dependable and reliable for both her circle of friends as well as family. Has a tendency to neglect her own needs out of a desire to put the needs of others before her own.
The patient's attitude was open and cooperative. Her mood and affect were congruent. Memory functions were intact with respect to immediate and remote recall of events and factual information. Her thought process appeared intact, goal oriented, and well organized. Thought content revealed no evidence of delusions or hallucinations. At this time the client denies having homicidal ideations and reports to have a very positive outlook no matter how long the process of adoption takes. There was no evidence of perceptual disorder. Her insight into any stressors or struggles within her current situation appear to be normal.
| Client A | 40 y.o. white female | |
| | | |
| Consciousness | Alert | |
| Orientation | x3 | |
| Attention/ Concentration | No apparent disturbances | |
| Appearance | Consistent with stated age | |
| Eye Contact | Good | |
| Dress | Appropriate | |
| Grooming | Good | |
| Motor Functioning | No apparent disturbances | |
| Gait | No apparent disturbances | |
| Visual Perception | No Impaired vision | |
| Speech | No apparent disturbances | |
| Prosody* | No apparent disturbances | |
| Auditory Comprehension | No apparent disturbances | |
| Immediate Memory | No apparent disturbances | |
| Recent Memory | No apparent disturbances | |
| Remote Memory | No apparent disturbances | |
| Estimated Intellectual Ability | Above Average | |
| Executive functioning | No apparent disturbances | |
| Affect | Appropriate | |
| Mood | Calm/Happy | |
| Interpersonal Behavior | Cooperative | |
| Suicidal Ideation | Absent | |
| Homicidal Ideation | Absent | |
| Thought Content | Appropriate | |
| Thought Processes | Reality Oriented | |
| Delusions | None | |
| Hallucinations | None | |
| Judgment/ Reasoning | Good | |
| Insight | Good | |
Note: x3 = oriented to person, place, & time.
*Prosody may reflect the emotional state of a speaker; the rhythm, stress, and intonation of speech
RESULTS OF EVALUATION:
The Beck Depression Inventory was administered to this client. Her score indicated that she would be placed in the minimal category of depression. The BDI-II also indicated that she is currently experiencing some environmental/situational stress that could be causing her minor depressive disorder.
The Beck Anxiety Inventory indicates that this client is also experiencing some mild anxiety. The anxiety appears to be generalized around this particular time of her life and what is going to happen next.
On The Basic Personality Inventory none of the validity indices are out of normal limits, indicating that the BPI was completed purposefully and that the results may be interpreted accordingly. The reliability index is in the normal range and indicates consistent responding throughout the BPI. The perseveration index indicates a normal pattern of responses. There were no omitted or incorrectly marked responses.
The BPI revealed that the client is well within average for her age group and professional group. There did not appear to be any major concerns in the results.
It appears that she sees herself in a positive aspect. She is not easily influenced by the opinions of others, but rather trusts her judgment in the decisions that she makes and feels very confident in her ability to hold a full-time professor role at SMU as well as healthfully raise a child as a single parent. She appears to have a plan and support group in helping to raise the child as she is working full-time. At this time she has no intention of introducing an additional person (i.e. boyfriend or husband) to the child’s life and feels confident that if the situation should arise she would be able to handle it accordingly and in the best interest of the child.
DIAGNOSIS:
AXIS I 311 Depressive Disorder, NOS
AXIS II None
AXIS III None
AXIS IV Stress from adoption process on top of demands from work with students
AXIS V 75 GAF: Current
RECOMMENDATIONS:
It is recommended that the client see a psychiatrist for possible medication for depression. This client would benefit from cognitive behavioral therapy as needed throughout the adoption process. Client should be encouraged as she continues through the application/interview process of adopting. Family therapy for client and adopted child upon completion of process would be encouraged. Parenting classes and/or a a support group for adopted parents is strongly recommended as this is the first child for the client and she has every intention of raising the child alone. This client has the potential to make a productive impact on the life of a child as well as her students at SMU.
Please let me know if any additional information is needed concerning the results of this evaluation.
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