Download the accompanying electronic forms - Springer

166 Pages·2012·13.3 MB·English

Forms and Templates for Effective Practice
Provided to Supplement
Clinician’s Guide to Psychological Assessment
and Testing
John M. Spores, PhD, JD
ISBN: 978-0-8261-9945-4
Digital Product
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Contents
Assessment and Test Battery–Adult 1
Assessment and Test Battery–Child 2
Competency Examination 3
Conners’ CAARS–L, Self-Report and Observer Forms 9
Conners CBRS, Parent and Self-Report Forms 10
Conners CBRS, Parent and Teacher Forms 12
Conners CBRS, Self-Report Form 14
Conners EC, Parent and Teacher/Childcare Forms 16
CPT–II 18
GADS 19
GARS–2 20
Initial Psychological Assessment Report–Adult 21
Initial Psychological Assessment Report–Child 27
K–CPT 33
Legal System Questionnaire 35
MACI 37
MCMI–III 40
MMPI–2–RF 43
MMPI–A 48
MMSE–2–BV 51
MMSE–2–EV 52
MMSE–2–SV 53
M–PACI 54
NAB, Form 2, Attention Module 56
NAB, Form 1 57
NASB, Form 1 59
NEPSY–II, Form Ages 3 to 4, Full Battery 62
NEPSY–II, Form Ages 3 to 4, General Battery 65
NEPSY–II, Form Ages 5 to 16, Full Battery 67
NEPSY–II, Form Ages 5 to 16, General Battery 71
Patient Test Instruction Form 73
Psychological Test Listing Form 74
Psychological Test Referral Form 75
Psychological Test Request and Log Form 76
Roberts–2 78
Rorschach–CS, Ages 5 to 7 82
Rorschach–CS, Ages 8 to 10 87
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iv Contents
Rorschach–CS, Ages 11 to 14 92
Rorschach–CS, Ages 15 to 17 97
Rorschach–CS, Ages 18 to 86 102
Treatment Recommendations 107
Treatment Recommendations 108
Vineland–II, Survey Interview Form 109
WAIS–IV 111
WAIS–IV–WIAT–III, K–12 113
WAIS–IV–WIAT–III, K–12 118
WAIS–IV–WMS–IV, Form Ages 16 to 69 122
WAIS–IV–WMS–IV, Form Ages 16 to 69 126
WAIS–IV–WMS–IV, Form Ages 65 to 90 130
WAIS–IV–WMS–IV, Form Ages 65 to 90 134
WIAT–III, K–12 137
WIAT–III, PK 140
WISC–IV 141
WISC–IV–WIAT–III, K–12 143
WISC–IV–WIAT–III, K–12 149
WMS–IV, Form Ages 16 to 69 154
WMS–IV, Form Ages 65 to 90 157
WPPSI–III, Form Ages 2:6 to 3:11 159
WPPSI–III, Form Ages 4:0 to 7:3 161
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Assessment and Test Battery–Adult 1
Assessment And test BAttery–Adult
1. Diagnostic Interview (//)
2. Mental Status Examination (//)
3. Mental Status Examination Including the Mini-Mental State Examination, Second Edition,
Expanded Version, Blue Form (MMSE–2–EV–BF) (//)
4. Mental Status Examination Including the Mini-Mental State Examination, Second Edition, Standard
Version, Blue Form (MMSE–2–SV–BF) (//)
5. Mental Status Examination Including the Mini-Mental State Examination, Second Edition, Brief
Version, Blue Form (MMSE–2–BV–BF) (//)
6. Mental Status Examination Including the Mini-Mental State Examination (MMSE) (//)
7. Wechsler Adult Intelligence Scale, Fourth Edition (WAIS–IV) (//)
8. Wechsler Memory Scale, Fourth Edition (WMS–IV), Form Ages 16 to 69 (//)
9. Wechsler Memory Scale, Fourth Edition (WMS–IV), Form Ages 65 to 90 (//)
10. Ability–Memory Discrepancy Analysis (//)
11. Wechsler Individual Achievement Test, Third Edition, K–12 (WIAT–III, K–12) (//)
12. Ability–Achievement Discrepancy Analysis (//)
13. Neuropsychological Assessment Battery (NAB), Form 1 (//; //)
14. Neuropsychological Assessment Battery (NAB), Form 2, Attention Module (//)
15. Neuropsychological Assessment Screening Battery (NASB), Form 1 (//)
16. Neuropsychological Assessment Battery (NAB), Form 1, ## and ## Modules (//)
17. Millon Clinical Multiaxial Inventory–III (MCMI–III) (//)
18. Minnesota Multiphasic Personality Inventory–2–Restructured Form (MMPI–2–RF) (//)
19. Minnesota Multiphasic Personality Inventory–2 (MMPI–2) (//)
20. Rorschach Inkblot Test, Comprehensive System, RIAP Fifth Edition (Rorschach–CS), Ages 18 to 86 (//)
21. Conners’ Continuous Performance Test, Second Edition, Version 5 (CPT–II) (//)
22. Conners’ Adult ADHD Rating Scales, Long Version (CAARS–L), Self–Report and Observer Forms (//)
23. Vineland Adaptive Behavior Scales, Second Edition (Vineland–II) (//)
24. Legal System Questionnaire (LSQ) (//).
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01_ASSESSMENT AND TEST BATTERY-ADULT.indd 1 9/17/12 11:43 AM
2 Forms and Templates for Effective Practice
Assessment And test BAttery–Child
1. Diagnostic Interview (//)
2. Mental Status Examination and Behavioral Observations (//)
3. Conners’ Continuous Performance Test, Second Edition, Version 5 (CPT–II) (//)
4. Conners’ Kiddie Continuous Performance Test, Version 5 (K–CPT) (//)
5. Conners Comprehensive Behavior Rating Scales (Conners CBRS), Parent and Teacher Forms (//)
6. Conners Comprehensive Behavior Rating Scales (Conners CBRS), Parent and Self–Report Forms (//)
7. Conners Comprehensive Behavior Rating Scales (Conners CBRS), Self–Report Form (//)
8. Conners Early Childhood (Conners EC), Parent and Teacher/Childcare Forms (//)
9. NEPSY–II, Form Ages 3 to 4, Full Battery (//)
10. NEPSY–II, Form Ages 5 to 16, Full Battery (//)
11. NEPSY–II, Form Ages 3 to 4, General Battery (//)
12. NEPSY–II, Form Ages 5 to 16, General Battery (//)
13. NEPSY–II, Form Ages 3 to 4, Social Perception Subtests (//)
14. NEPSY–II, Form Ages 5 to 16, Social Perception Subtests (//)
15. NEPSY–II, Form Ages 3 to 4, Attention and Executive Functioning, Memory and Learning Subtests (//)
16. NEPSY–II, Form Ages 5 to 16, Attention and Executive Functioning, Memory and Learning
Subtests (//)
17. NEPSY–II, Form Ages 3 to 4, Attention and Executive Functioning, Memory and Learning, Social
Perception Subtests (//)
18. NEPSY–II, Form Ages 5 to 16, Attention and Executive Functioning, Memory and Learning, Social
Perception Subtests (//)
19. Gilliam Autism Rating Scale, Second Edition (GARS–2) (//)
20. Gilliam Asperger’s Disorder Scale (GADS) (//)
21. Millon Pre–Adolescent Clinical Inventory (M–PACI) (//)
22. Millon Adolescent Clinical Inventory (MACI) (//)
23. Minnesota Multiphasic Personality Inventory–Adolescent (MMPI–A) (//)
24. Rorschach Inkblot Test, Comprehensive System, RIAP Fifth Edition, (Rorschach–CS), Ages 5 to 17 (//)
25. Roberts–2 (//)
26. Vineland Adaptive Behavior Scales, Second Edition (Vineland–II) (//)
27. Wechsler Intelligence Scale for Children, Fourth Edition (WISC–IV) (//)
28. Wechsler Preschool and Primary Scale of Intelligence, Third Edition (WPPSI–III), Form Ages 2:6 to
3:11 (//)
29. Wechsler Preschool and Primary Scale of Intelligence, Third Edition (WPPSI–III), Form Ages 4:0 to
7:3 (//)
30. Wechsler Adult Intelligence Scale, Fourth Edition (WAIS–IV) (//)
31. Wechsler Individual Achievement Test, Third Edition, Pre-Kindergarten
(WIAT–III, PK) (//)
32. Wechsler Individual Achievement Test, Third Edition, K–12 (WIAT–III, K–12) (//)
33. Ability–Achievement Discrepancy Analysis (//)
34. Wechsler Memory Scale, Fourth Edition (WMS–IV), Form Ages 16 to 69 (//)
35. Ability–Memory Discrepancy Analysis (//).
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02_ASSESSMENT AND TEST BATTERY-CHILD.indd 2 9/17/12 11:51 AM
Competency Examination 3
CompetenCy examination
State of ________ vs. _________
Cause number: 64D45-5647-001
Community mental Health Center, inc. outpatient Department
Competency examination
Defendant name: Last, First
examination Date: november 4, 2012
Office File Number: 000000
Legal Case Title: State of _________ vs. _________
Cause Number: 64D45-5647-001
Judge: Name
Court: Name of Court
Examiner: Psychologist Name, PhD, PsyD, HSPP
Psychologist – State License #0000000000
Note. Mr. ______ was initially informed that all data gathered during the course of this evalua-
tion would be released to the above listed Court pursuant to court order, and subsequently to
the attorneys of record in the above listed cause(s). He acknowledged that he understood and
v erbally consented.
i. identifying information:
Mr. _____’s age is years months. Gender is male. DOB: //.
ii. presenting Legal issue(s):
A. Criminal Charges:
B. Court Order:
Judge ______ ordered that Mr. _____ be examined to determine his competency to stand trial.
State Statute § ##-##-#-#(#) (####).
iii. assessment and test Battery:
A. Clinical Diagnostic Interview (//)
B. Mental Status Examination Including the Mini-Mental State Examination, Second Edition,
Extended Version, Blue Form (MMSE–2–EV–BF) (//)
C. Rorschach Inkblot Test, Comprehensive System, RIAP Fifth Edition (Rorschach–CS), Ages 18 to
86 (//)
D. Legal System Questionnaire (LSQ) (//)
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03_COMPETENCY EXAMINATION.indd 3 20/09/12 6:55 PM
4 Forms and Templates for Effective Practice
CompetenCy examination (Cont.)
State of ________ vs. _________
Cause number: 64D45-5647-001
iV. assessment and test Results:
A. Clinical Diagnostic Interview:
Note. All information in this section is based on statements made by the defendant in response
to interview questions, or by available archival records and reports.
1. Presenting Symptoms:
Mr. _____ complained of _____.
2. Family Psychiatric History:
3. Social History:
4. Educational History:
5. Vocational History:
6. Substance Abuse History:
7. Psychiatric/Medical History:
8. Legal History Prior to Current Charges:
B. Mental Status Examination including the Mini-Mental State Examination, Second E dition,
Extended Version, Blue Form (MMSE–2–EV–BF):
Table 1 n MMSE–2–EV–BF RESultS
Cognitive function Patient’s raw score Maximum possible raw score
Registration 3 3
Orientation to Time 5 5
Orientation to Place 5 5
Recall 3 3
Attention and Calculation 5 5
Naming 2 2
Repetition 1 1
Comprehension 3 3
Reading 1 1
Writing 1 1
Drawing 1 1
Story Memory 25 25
Processing Speed 35 35
Total Raw Scorea 90 90
Note. Lower raw scores indicate greater cognitive dysfunction. Overall cognitive function data are in boldface.
aRaw scores of 50 or less indicate cognitive impairment.
MMSE–2–EV–BF Result: Negative Positive for cognitive impairment.
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03_COMPETENCY EXAMINATION.indd 4 20/09/12 6:55 PM
Competency Examination 5
CompetenCy examination (Cont.)
State of ________ vs. _________
Cause number: 64D45-5647-001
Mr. _______ was oriented to person, stating and spelling his full name and providing his date of
birth accurately, when compared to independent court and mental health records. He was ori-
ented to time and place as evidenced by the MMSE–2–EV–BF results. Immediate and interme-
diate memory functions were normal and intact as evidenced by the MMSE–2–EV–BF results.
Long-term memory was intact as evidenced by Mr. _______ providing a coherent developmen-
tal history. Mr. ________’s intellectual functioning was estimated to be average based upon his
verbal skills, reasoning abilities, and the MMSE–2–EV–BF results. Thought process was logical,
sequential, relevant, and c oherent. Thought content was normal and reality based. P sychotic
symptoms were not evident. Affect was mildly restricted. Mood was mildly dysphoric.
Mr. _____ denied any current suicidal or homicidal thoughts, intentions, or plans. There was
no current evidence of self-mutilation or self-harm.
C. Rorschach Inkblot Test, Comprehensive System, RIAP Fifth Edition (Rorschach–CS),
Ages 18 to 86:
Table 2 n tESt Validity: Situational GuaRdEdnESS
Variable Score Expected Positive result range Resulta Meaning of positive result
range
R 00 18 – 29* ≤ 13† Negative Excessively nonproductive; defensive.
Note. * denotes that the listed range is based on –1.00 to +1.00 standard deviations from the normative mean including rounding for
ease of interpretation. † denotes that the listed range is determined by Comprehensive System interpretation guidelines.
aWhen R < 14, the entire Rorschach protocol is per se invalid; there is insufficient test data for meaningful scoring and interpretation.
There is no evidence of situational guardedness. In this regard, the clinical variables are deemed valid.
There is remarkable situational guardedness. Therefore, this test is deemed invalid. The remaining
scores are neither interpreted nor reported.
Table 3 n tESt Validity: SyMptoM ExaGGERation
Variable Score Expected range Positive result range Resulta Meaning of positive result
X–%b 0.00 0.00 – 0.18* ≥ 0.70† Negative Exaggerating or malingering symptoms.
XA+% 0.00 0.80 – 0.95* ≥ 0.75†† Positive Indications of adequate reality testing.
X–% 0.00 0.00 – 0.18* ≥ 0.26† Negative Extremely distorted thinking.
Note. * denotes that the listed range is based on –1.00 to +1.00 standard deviations from the normative mean including rounding for
ease of interpretation. † denotes that the listed range is determined by Comprehensive System interpretation guidelines. †† denotes
that the listed range is determined by the percentage base rate in the norm reference sample due to skewness in that variable’s
frequency distribution.
aWhen the first row variable is X–% < 0.70 and hence negative, both remaining variables must yield positive results to indicate an
invalid response pattern.
bX–% ≥ 0.70 indicates such gross psychological impairment that testing would have been precluded; therefore the entire Rorschach
protocol is deemed per se invalid irrespective of the remaining variables.
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6 Forms and Templates for Effective Practice
CompetenCy examination (Cont.)
State of ________ vs. _________
Cause number: 64D45-5647-001
There is no evidence of exaggeration of symptoms or malingering. In this regard, the clinical vari-
ables are deemed valid.
There is remarkable evidence of an intentional exaggeration of symptoms or m alingering. Therefore,
the clinical variables are deemed invalid. The remaining scores are neither interpreted nor reported.
The paradoxical data of adequate reality testing and extremely distorted thinking is evidence of an
intentional exaggeration of symptoms or malingering. Therefore, the clinical variables are deemed in-
valid. The remaining scores are neither interpreted nor reported.
There exists evidence of a tendency towards magnifying symptoms. Therefore, the ensuing Ror-
schach variables are considered credible when reasonably supportive of other reliable and valid test
data, including information gathered during the diagnostic interview.
Table 4 n  CliniCal VaRiaBlES: pSyChotiC diSoRdERS
Variable Score Expected range Positive result Result Meaning of positive result
range
WSum6 00 0 – 18** ≥ 19†σ Negative Ideational or cognitive slippage; formal
thought disorder.
Level 2 00 0†† ≥ 1†† Positive Manifestly bizarre responses.
PTI 0 0 – 2†† 3 – 5†† Negative Psychotic index; psychotic
disorder.
XA+% 0.00 0.74 – 1.00** ≤ 0.73†σ Negative Disturbed mediation or reality testing.
WDA+% 0.00 0.79 – 1.00** ≤ 0.78†σ Negative Pervasively disturbed mediation or reality
testing.
X–% 0.00 0.00 – 0.25** ≥ 0.26†σ Positive Extremely distorted thinking.
Note. PTI = Perceptual Thinking Index. ** denotes that the listed range is based on –2.00 to +2.00 standard deviations from the
normative mean including rounding for ease of interpretation. † denotes that the listed range is determined by Comprehensive System
interpretation guidelines. †† denotes that the listed range is determined by percentage base rate in the norm reference sample due to
that variable’s skewed distribution. σ denotes that the listed positive result range is based on the deviation principle.
The psychotic disorders variables…
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