Introduction
be sure to include client name, DOB and age at testing, date of testing, examiner, supervisor, place of evaluation, and reason for referral, client arrival (on time, late, alone, accompanied by someone…).

Procedures
Tests used, information and records available, collateral contacts made, if any tests were attempted but were invalid or incomplete you could note it here too.

Background and History
From your excellent background interview, you'll include information that is relevant to the task at hand. You don't include every detail you get, only what is really relevant to the referral source and the referral question.

Mental Status Exam and Behavioral Observations
From your excellent observational skills, you are trying to document how the client is functioning in the moment you saw them, including signs of cognitive, emotional, and social impairment.

Test Results
Varies by site and referral, but may be by test, by referral issue, or by area of functioning. I have included in my reports disclaimers about the limits of testing, important points about their reliability and validity, and sometimes explanations simply to let the reader know why I gave a test and what it tells me. Occassionally, I'll also add research data to support my conclusions from a test; for example, "This test has been shown to distinguish between abusive and non-abusive parents with 93% accuracy." I have also begun adding the "if-there-are-other-records-I-didn't-receive" disclaimer, as I have found that there very often are records I was told did not exist or records that were "lost" but "found" by some "amazing grace"… that would have impacted my decision had they been made available to me.

Summary
Brief review of reason for referral, background, and findings. Not a conclusive section, but only a brief review of the relevant results of the report to refresh the reader's mind before moving onto conclusions. There of course should be nothing new in this sections, as it is only a summary.

Conceptualization and Conclusions
Integration of findings, discussion of their meaning, and salient issues to be addressed. Some may ask you to repeat the referral questions one by one and answer them clearly.

Diagnosis
When required do the full DSM IV Five Axis List, including Axis II Personality Disorders. If you are worried about this for the reader, you can do what I sometimes do. I add "A Note:" at the end of the diagnostic section explaining what the diagnosis means, why I gave a Rule Out, or why the diagnosis given may contradict past records or not be what the referral source expected.

Recommendations
Based on the above, what would be needed in the case, with some special pointers, such as:

Therapy (type, duration, sex of therapist, level of training) and whether it is "traditional" in focus or recommended as an "inoculation." For example, step-family formation is a traumatic process that can lead to two to three years of distress for the family if the family is unclear on what to expect and how to handle it. Therapy to educate the family on how it will likely go and what it will be like can prevent some problems, help them prepare for others, and minimize the damage caused by some

educational intervention (IEP, teacher and parent suggestions for an LD or ADHD child, tutoring, extended testing, reconsideration of placement, mainstreaming, special education or therapeutic day school placement)

remediation efforts or skills training (vocational training, parenting support group, anger management classes, assertiveness skills, GED program, reading and literacy workshops)

psychiatric or medication evaluation (for what problem, what diagnostic confusion might be had, any special preparation the client or family will need)

substance abuse treatment (inpatient, outpatient, support groups and attendance schedule, urine screenings, comorbid disorders that would complicate treatment)

group services (therapy, victims of abuse support, single parents, 12 Step, grief and loss group, depression or other diagnosis treatment group, couples workshop)

psychological evaluation (what for and when, and I've started adding by whom and alternatives if this can't be paid for by the agency, such that the therapist might be able to offer an evaluation… some therapists don't want this put on them though, as being placed in a clearly evaluative setting can compromise their therapeutic work)

community services (church, Big Brothers/Sister, after school activities, adult social group, stress management classes)

warning on suicide, violence, relapse risk

re-evaluation as needed (hearing and vision, neurological, speech, vocational, IEP… when and why). I also suggest that the referral source let the next evaluator know of this evaluation since some of the tests could be duplicated and then practice effects would skew the results

hospitalization due to noted reason (e.g., decompensation, failure of outpatient treatment, suicide risk, eating disorder that presents a risk to physical health, risk to harm others, bizarre or progressively risky behaviors that present a danger to self, dementia)

I have begun adding a"if-you-don't-like-these-recommendations" section as well, as other information may be available to courts and other agencies that would negate my results, and the court may not know how to integrate the two sets of findings or may have a different set or priorities than I do