A report that details the findings of a comprehensive psychological assessment. When contextual information is provided by the clinician, combined with clinical interview(s) on NovoNote and NovoPsych psychometrics, this report will synthesise the available data into a coherent evaluation.
This template can assist clinicians in preparing a draft report for a number of purposes, such as medical, legal, insurance, and client feedback.
Recipient Name and Address
Re: Client Name, DOB, Address
Dear Recipient Name,
The following report is a comprehensive psychological evaluation of Client Name.
Provide a summary of the purpose of the evaluation and the client’s associated presenting concerns. Describe any relevant personal information e.g., age and gender of client; cultural background; and any modifications or assistive measures required for the evaluation or other context leading to the assessment.
Information sources:
List clinical interviews, psychometric assessments, and third-party documents used to inform the report.
Personal and developmental history:
Provide summary of early development, family history, education, employment, current living arrangements, trauma history, and family mental health history.
Medical status and medical history:
Describe previous non-psychiatric diagnoses, medical conditions, and treatment responses.
Mental health history:
Detail previous mental health diagnoses, psychiatric conditions, psychological interventions, hospitalisations, and treatment responses.
Medication history:
List current medications with doses and frequencies, past medication responses, side effects, and adherence.
Drug and alcohol use history:
Summarise current and past substance use including alcohol, tobacco, recreational drugs, and prescription medication misuse.
Other addiction history:
Detail potentially problematic addictive behaviours such as gambling, gaming, internet use, or other behavioural addictions.
Legal and forensic history:
Describe history of illegal activity, justice system interactions, imprisonment, family law involvement, or domestic violence.
Current presentation:
Provide detailed summary of current symptoms, duration, external stressors, relationship factors, functional impact, lifestyle indicators, sleep patterns, diet, physical activity, and social functioning.
Mental status examination (MSE):
Provide narrative summary of appearance, behaviour, speech, mood/affect, thought process, thought content, perception, cognition, and insight/judgment.
Strengths, coping skills, recreational interests, and hobbies:
Summarise client strengths, positive coping mechanisms, interests, and protective factors.
Psychometric assessment:
For each assessment, provide name, description, administration date, purpose, quantitative results, interpretation, and clinical implications.
Functional assessment:
Describe current functioning across daily living skills, social/interpersonal functioning, occupational/academic functioning, and self-care/independence.
Formulation/impression:
Provide bio-psycho-social formulation including predisposing, precipitating, perpetuating, and protective factors, with psychodynamic elements if applicable.
Diagnosis:
Detail diagnostic impressions, if stated by the clinician, based on DSM-5-TR and ICD-11 criteria, with rationale, relevant criteria met, supporting evidence, codes, and differential considerations.
Risk:
Assess risk of suicide, self-harm, harm to others, or relapse, including past attempts, psychosocial stressors, and protective factors.
Recommendations:
Detail the clinician’s recommendations regarding medication, non-pharmacological interventions, referrals, diagnosis-specific management, lifestyle modifications, workplace/academic accommodations, follow-up plans, and safety planning.
Prognosis:
Provide clinician’s opinion on likely course of presenting conditions, influencing factors, and likelihood of improvement with recommended interventions.
Summary:
Brief paragraph summarising the evaluation, formulation, and diagnosis.
Yours sincerely,
Clinician Name
Dr. Amelia Richardson
Northern Sydney Mental Health Services
1 Harbour Street
Sydney NSW 2060
Re: James Woods, DOB 18/03/1992, 1 Wattle Avenue, Chatswood NSW 2067
Dear Dr. Richardson,
The following report is a comprehensive psychological evaluation of James Woods.
Mr. Woods is a 33-year-old male referred by his general practitioner for psychological assessment due to persistent symptoms of anxiety and depression following a workplace injury six months ago. He reports increasing social withdrawal, sleep disturbance, and difficulty managing daily responsibilities.
Information sources:
Personal and developmental history:
Mr. Woods reported an unremarkable developmental history with no significant delays. He grew up in Sydney with both parents and one younger sister in a stable home environment. He completed his HSC with above-average results and obtained a Bachelor of Business from Macquarie University. Mr. Woods has worked in finance for ten years and was recently promoted before his injury. He currently lives with his partner of five years. Family history includes anxiety disorder in his mother and alcohol use disorder in a paternal uncle.
Medical status and medical history:
Mr. Woods suffered a lower back injury (L4-L5 disc herniation) in November 2024. He has undergone conservative treatment including physiotherapy and pain management. He has mild asthma diagnosed in childhood, well-controlled with occasional use of a salbutamol inhaler.
Mental health history:
Mr. Woods reported a previous episode of depression during his final year of university (2013), for which he attended six sessions of counselling through the university health service with complete remission following graduation. No psychiatric hospitalisations or other mental health interventions were reported.
Medication history:
Current medications include paracetamol 500mg as needed for back pain (typically 2-3 times weekly) and salbutamol inhaler as needed for asthma (rarely used). No current psychotropic medications.
Drug and alcohol use history:
Mr. Woods reports moderate alcohol consumption of 2-3 standard drinks, 2-3 times per week. No current tobacco use, illicit substance use, or prescription medication misuse.
Current presentation:
Mr. Woods presents with symptoms of low mood, anhedonia, fatigue, irritability, and anxiety that have progressively worsened since his workplace injury. He reports ruminating thoughts about his career trajectory and financial stability. Sleep is significantly disrupted (averaging 5 hours per night) with a 4kg weight loss over three months. Mr. Woods has withdrawn from social activities and describes feeling “useless” due to physical limitations. He continues to work remotely on modified duties but reports decreased productivity and concentration difficulties. His relationship with his partner remains supportive but strained by his mood changes.
Mental status examination (MSE):
Mr. Woods presented as well-groomed with appropriate eye contact though frequently shifting position due to discomfort. Speech was normal in rate and volume. Mood was described as “frustrated and worried” with congruent, restricted affect. Thought process was logical with no evidence of thought disorder. Thought content revealed preoccupation with health concerns and future employability, but no delusions or suicidal ideation. Cognition appeared intact with normal attention and memory. Mr. Woods demonstrated good insight into his difficulties.
Strengths, coping skills, recreational interests, and hobbies:
Mr. Woods demonstrates problem-solving abilities and maintains a structured daily routine despite limitations. His supportive relationship and family communication serve as protective factors. Prior to injury, he enjoyed bushwalking, photography, and recreational football. He currently engages in modified photography activities and uses mindfulness applications intermittently.
Psychometric assessment:
Depression Anxiety Stress Scales – Short Form (DASS-21)
The DASS-21 is a self-report measure designed to assess the negative emotional states of depression, anxiety, and stress.
Results (04/05/2025):
Interpretation: Mr. Woods’s DASS-21 scores indicate he is experiencing a clinically significant degree of psychological distress. His depression score falls in the severe range, suggesting marked low mood, loss of self-esteem and incentive, and a sense of hopelessness about the future. His anxiety score falls in the moderate range, indicating heightened autonomic arousal, situational anxiety, and subjective experiences of anxious affect. His stress score falls in the severe range, suggesting persistent tension, a low threshold for becoming upset, and difficulties relaxing.
Patient Health Questionnaire – Depression (PHQ-9)
The PHQ-9 is a self-report measure designed to screen for and assess the severity of depression.
Results (04/05/2025):
Interpretation: Mr. Woods’s total score on the PHQ-9 falls in the moderately severe range, indicating pronounced depressive symptoms that significantly impact daily functioning and quality of life. His responses indicate particular difficulties with sleep, energy levels, and concentration. No endorsement of suicidal ideation was noted on item 9.
Generalised Anxiety Disorder Assessment (GAD-7)
The GAD-7 is a brief self-report measure designed to screen for and assess the severity of generalised anxiety disorder.
Results (04/05/2025):
Interpretation: Mr. Woods’s GAD-7 total score falls in the moderate range, indicating notable levels of anxiety with frequent symptoms that impact daily functioning. He reported particular difficulty with worry, restlessness, and irritability. His pattern of symptoms is consistent with generalised anxiety, especially related to health and occupational concerns.
Functional assessment:
Mr. Woods manages basic self-care independently but reports pain with prolonged standing or bending. Social functioning shows significant withdrawal from activities and friends. He continues working remotely on modified duties with reduced productivity and concentration difficulties. While maintaining basic independence, he has become increasingly reliant on his partner for transportation and some household tasks.
Formulation/impression:
Mr. Woods’s presentation involves biological factors (pain, sleep disruption), psychological factors (perfectionistic tendencies, catastrophic thinking), and social factors (work identity tied to self-worth). His symptoms appear to involve adjustment difficulties following physical injury, with pre-existing perfectionistic traits exacerbating his response. A negative cycle has developed wherein pain leads to activity restriction, which increases focus on pain and negative thoughts, further reducing motivation and reinforcing depression.
Diagnosis:
Based on clinical interview and psychometric assessment, Mr. Woods meets criteria for: Major Depressive Disorder, Moderate (F32.1) Evidenced by persistent low mood, anhedonia, fatigue, sleep disturbance, weight loss, and concentration difficulties.
Risk:
Mr. Woods denies current suicidal ideation, intent, or plan. No history of suicide attempts or self-harm was reported. Risk factors include chronic pain, depression, and employment concerns. Protective factors include stable housing, supportive relationship, and willingness to engage in treatment. Overall suicide risk is assessed as low at present.
Recommendations:
Prognosis:
Mr. Woods’s prognosis is cautiously optimistic given his absence of previous chronic mental health conditions, good premorbid functioning, stable relationship, and treatment engagement. With appropriate multidisciplinary treatment, significant improvement may be expected within 3-6 months.
Summary:
Mr. Woods is a 33-year-old male presenting with Major Depressive Disorder following a workplace back injury six months ago. His presentation involves interaction between physical pain, negative cognitions, and mood symptoms, significantly impacting functioning. A multidisciplinary approach including psychological intervention, medication evaluation, and continued physical rehabilitation is recommended.
If you have any questions about the contents of this report, please feel free to contact me.
Yours sincerely,
Dr. Marcus Jones
Clinical Psychologist
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