Components to Request in a Psychological Evaluation
When requesting a psychological evaluation, you should specifically ask for a comprehensive assessment that includes psychiatric history, mental status examination, risk assessment, and treatment recommendations as outlined in the American Psychiatric Association practice guidelines.
Core Components to Request
1. Comprehensive Psychiatric History
- Current presenting symptoms and reason for evaluation 1
- Past and current psychiatric diagnoses 1
- Prior psychiatric hospitalizations and emergency department visits 1
- Previous psychiatric treatments and their effectiveness 1
- Medication history (including dosages, duration, response, and adherence) 1
- Substance use history (tobacco, alcohol, illicit drugs, prescription misuse) 1
- Trauma history 1
- Psychosocial stressors (financial, housing, legal, occupational, relationship) 1
2. Medical History Assessment
- Current and past medical conditions 1
- Current medications (prescribed, over-the-counter, supplements) 1
- Medication allergies 1
- Neurological conditions or symptoms 1
- Physical trauma, especially head injuries 1
- Primary care relationship status 1
3. Mental Status Examination
- General appearance and behavior 1
- Speech characteristics 1
- Mood and affect 1
- Thought content and process 1
- Perceptual disturbances (hallucinations) 1
- Cognitive assessment (attention, memory, executive function) 1
- Insight and judgment 1
4. Risk Assessment
- Current suicidal ideation, plans, and attempts 1
- Access to means and protective factors 1
- History of suicidal behavior 1
- Current aggressive or homicidal ideation 1
- History of violent behaviors 1
- Self-harm behaviors without suicidal intent 1
5. Standardized Assessment Tools
- Request quantitative measures to identify and determine symptom severity 1
- Neuropsychological testing if cognitive concerns are present 1
6. Family History
- Psychiatric disorders in biological relatives 1
- History of suicidal behaviors in family (if relevant) 1
- History of violent behaviors in family (if relevant) 1
7. Social and Cultural Assessment
- Cultural factors related to the patient's environment 1
- Personal/cultural beliefs about mental illness 1
- Support systems 1
Special Considerations for Different Populations
For Children and Adolescents
- Interviews with both child and parents (together and separately) 1
- Developmental history and assessment 1
- School functioning and academic performance 1
- Collateral information from teachers or other caregivers 1
For Patients with Cognitive Concerns
- Comprehensive neuropsychological testing of learning, memory, attention, executive function, visuospatial function, and language 1
- Assessment of daily functioning 1
For Patients with Possible Psychotic Disorders
- Detailed assessment of psychotic symptoms 1
- Evaluation of tobacco and substance use 1
- Physical health assessment 1
Final Documentation to Request
- Clear diagnostic impressions 1
- Suicide risk assessment with specific risk factors 1
- Treatment recommendations with rationale 1
- Recommended level of care 1
- Follow-up plan 1
Common Pitfalls to Avoid
- Failing to specify the reason for referral or consultation question
- Not requesting collateral information from family members or other providers
- Overlooking the need for standardized assessment tools
- Neglecting to ask for specific treatment recommendations
- Failing to request assessment of risk factors for suicide or violence
By specifically requesting these components, you'll ensure a thorough psychological evaluation that provides actionable information for treatment planning and risk management.