1 / 7100%
Running head: INITIAL INTERVIEW 1
Initial Interview
Would this examinee make a good Resident Assistant at Liberty University?
Angel M. Perez
Liberty University
INITIAL INTERVIEW 2
Identifying Information
Client name: Jesus Sanchez
Address: 34 Smith Court, Orlando, FL 32716
Phone number: (555) 555-1212
Age: 26
Gender: Male
Ethnicity: Puerto Rican
Place of birth: Bronx, New York
Marital status: Single
Occupation: Graduate student
Major: Ph.D. Clinical Psychology
School: University of South Florida
Work telephone numbers: N/A
Name of another person to contact in case of an emergency: Milagros Gerena, 3212 Gulfview
Drive, Altamonte Springs, FL 32771, (321)584-2468
Purpose of Counseling/Presenting Problem
Jesus Sanchez was referred by Liberty University for the purpose of a psychological
evaluation to determine if he qualifies as a good Resident Assistant (RA) at Liberty University.
Mr. Perez reported no problems or concerns. He stated that he is optimistic, concerning his
candidacy for the position as a RA. Mr. Sanchez stated that he is experiencing a little anxiety
with regard to his job search. He is excited and has high hopes about being given the
position.
INITIAL INTERVIEW 3
Physical Appearance
Mr. Sanchez presented an acceptable personal appearance for a doctor’s interview. He is
well groomed and presents good hygiene. Mr. Sanchez is 6 ft. tall and weighs 220 lbs. Mr.
Sanchez displays no evidence of physical deformities. He held a pencil appropriately and was
able to write and perform written tasks as required. He was right-handed. His vision is
20/20, therefore having no need for glasses. He displayed appropriate eye contact and no
abnormal motor coordination with intentional movement or at rest. He displayed
appropriate erect posture. Mr. Sanchez was polite and employed good or appropriate
mannerisms.
Present level of Functioning in Work/School, Relationships, and leisure
Mr. Sanchez was oriented to person, place and time. He did not appear to have any
difficulty concentrating. Throughout the interview, his mood was positive and expressed feelings
of being happy. His affect was consistent the content of the conversation and facial expressions.
He showed no depressive or anxious symptoms at this time. He was very cooperative and
demonstrated appropriate interpersonal characteristics. There was no evidence of any auditory or
hallucinatory phenomenon, compulsive or obsessive behavior, or eating disorders. There was no
apparent demonstration of impulsivity or manic behavior. He expressed himself very well.
Spanish is his primary language, but he appears to dominate English as if it were his primary
language. There is no accent in his speech when he speaks English or Spanish. His speech
pattern, rate and volume was normal. His receptive language is normal. He demonstrated good
recall and memory. He was able to recall information after five minutes and 30 minutes of lapsed
time intervals.
INITIAL INTERVIEW 4
Mr. Sanchez was alert and his responses were coherent and easy to understand. His
judgment and insight abilities appear to be functioning at an optimum level. He is very
charismatic, easy to establish a rapport with. His facial and emotional expressions included
happy, smiling, laughing, focused and interested. He expressed no evidence of suicidal or
homicidal ideations, or any risk of violence. His response to failure on test items was
disappointment, which he would internalize.
Based on questions posed to Mr. Sanchez, he demonstrated an above average level of
concentration and attention. His thought process appear to be above average, showing strengths
in logical thinking, reasoning, and association. Abstract thinking is another one of his strengths.
Mr. Perez scored in the overall Gifted range of intelligence on the WAIS-IV. The Gifted
range is 103 - 144. His Verbal Comprehension score was Gifted (range 130-144), his Perceptual
Reasoning score was Gifted (range 130 - 144), his Working Memory score was Gifted (range
130 - 144) and his Processing Speed score was Gifted (range 130 - 144).
The WIAT-II Achievement tests indicated Mr. Perez to be functioning in the Gifted (range
130 - 144) range in all overall areas of achievement including Reading, Mathematics, Written
Language and Oral Language. His individual subtest scores ranged from Above Average
(Reading Comprehension) to Gifted (Written Expression.)
Medical History and Current Status
Mr. Sanchez stated that he has no past or current health issues or complaints. His latest
physical examination was 30 days ago, August 1, 2013. He is currently under no medication. He
stated that he does not use street drugs and never has. He stated that he exercises daily, plays
sport, has a normal appetite and sleeps between seven and nine hours daily.
INITIAL INTERVIEW 5
Past Counseling Experiences or Psychiatric History
Mr. Sanchez has no past counseling experience. He stated that he has no psychiatric
history. He stated that this is his first visit to a psychologist.
Family Information
Mr. Sanchez is single and has no children. He currently lives in an apartment off campus
with a male roommate, who is also a graduate student at Liberty University. He comes from a
family of four with one sibling, his sister Stephanie. He stated that he grew up in a positive
Christian environment. He stated that he has never participated in any form of drug abuse. He
does not drink or smoke. He stated that there is no past counseling or psychiatric history in his
family. His parents were born and raised in Puerto Rico. Mr. Sanchez and his sister were raised
in Brooklyn, New York.
Social/Developmental History
Mr. Sanchez was raised in a multicultural community, Brooklyn, NY. He and his family
attended church every Sunday morning. At age 16 – 18, he participated as a youth leader for the
youth in his church. He is an active member in his local non-denominational church. He stated
that he holds strong ties to family and Christian values. He shows no evidence of developmental
irregularities.
Educational/Occupational History
Mr. Sanchez stated that he has no legal or military history. Mr. Sanchez earned a B.A. in
Psychology from the University of South Florida. He has worked as a youth counselor in
community service organizations, such as the YMCA, and summer youth camps during his
undergraduate career at the University of South Florida. Each of his jobs were temporary
positions. He stated that he love his work and considered it more like a hobby because it was fun,
INITIAL INTERVIEW 6
with no unmanageable work-related stress. He stated that he enjoys working in an environment
where he can help people and be a mentor. He completed an eight month counseling practicum
at the Orlando Mental Health Clinic, in Orlando, FL.
Cultural Influences
Mr. Sanchez is of Hispanic origin, Puerto Rican. He is a heterosexual. He was raised in
NYC, in a multicultural community. He has close ties to his Puerto Rican cultural roots. He is
fluent in Spanish and English. His first language is Spanish. His parents have a high school
education and did not attend college or university studies. He stated that he has experienced
discrimination growing up as a child when traveling outside his community. No definitive
internal or external barriers were observed. He stated that he has no racial or cultural issues, that
he has an understanding for those that do and loves them despite their ignorance.
Criteria Points
Possible
Points
Earned
Identifying information is provided (name, address, phone, DOB, gender,
marital status, occupation, work/school, work phone, emergency contact,
date of interview)
9 9
Referral question or presenting problem is documented. 9 9
The client’s physical appearance is provided.
Addresses proper MSE information. 54 54
A description is provided for the client’s present level of functioning in
work/school, relationships, and leisure.
Addresses proper MSE information.
54 51
Medical history, both past and present, is provided. 18 18
Past psychiatric history or past counseling experience is provided. 9 9
Family information is provided. 9 9
Social/developmental history is provided. 7 4
Occupational and educational history is provided. 7 7
Cultural influences are listed. 4 4
Total: 180 177
INITIAL INTERVIEW 7
Instructor’s comments: Great job – overall, you presented the information in an appropriate
manner that documented the client’s current mental status.
Powered by TCPDF (www.tcpdf.org)
Students also viewed