PSYCHOLOGICAL REPORT

Prepared by:

Heartche L. Selibio
Bachelor of Science in Psychology
Central Mindanao University

December 2023
 PSYCHOLOGICAL REPORT
I. Identifying Data

NAME Heart Lucido BIRTHDAY February 14, 2003

ADDRESS Maramag, AGE 20 years old
Bukidnon
SEX F YEAR-LEVEL 3rd-year
SCHOOL Central Mindanao University
REFFERED BY: Cristy, Cruz

II. Reason for Referral

Heart was referred by the university’s guidance counselor. Heart is concerned
with her coping strategies in facing stress during the hard times of her life. She is having
a hard time trying to manage her thoughts, emotions, and behavior in these. She is also
experiencing mood swings, extreme sadness, and behavioral changes.

III. Case Background

Background information was obtained from client and the client’s mother. Heart is
the eldest child of the three children of Mr. Cinto Lucido and Mrs. Che Lucido. She is
currently a third year BS Psychology student at Central Mindanao University. Heart has
consistently demonstrated academic diligence and a strong commitment to her studies.
According to her academic records, she has maintained an above-average grade point
average.
The Lucido family is a close-knit unit, and Heart shares a warm and supportive
relationship with her parents and two younger siblings. Mr. and Mrs. Lucido are actively
involved in the community, and their familial bond is characterized by open
communication and mutual respect. However, recent discussions with Heart and her
mother have hinted at emerging challenges that may be impacting the family dynamics.
Heart’s family is experiencing some financial crisis and Heart’s parents constantly argue
at home.
During the initial assessment, Heart expressed concerns related to increased
stress levels, difficulties in managing her academic workload, and a sense of emotional
overwhelm. Her mother highlighted noticeable changes in Heart's behavior, such as
increased withdrawal, changes in sleep patterns, weight loss and appetite loss, and a
decline in overall mood.
IV. Observational Data
a.) General appearance, attitude and behavior
Upon entering the room, Heart presents herself as a neatly dressed young
woman, wearing a combination of comfortable casual attire, and she is wearing light
makeup. Her overall grooming is meticulous, and her posture suggests a degree of
alertness but with a subtle undertone of tension. She makes eye contact when greeted,
although the duration of eye contact seems to vary, with occasional downward glances
as she settles into a chair. Throughout the initial moments of the assessment, Heart's
facial expressions appear somewhat dim, and there is a noticeable absence of genuine
smiles. As the conversation progresses, she maintains a polite and cooperative manner,
responding thoughtfully to questions being asked. However, there is a discernible
hesitancy in her speech, characterized by brief pauses.
Heart's body language provides additional insights into her emotional state. While
she initially sits with an upright posture, as the discussion turns towards her academic
experiences and personal challenges, she exhibits signs of increased tension. There is
a subtle clasping of hands, and her shoulders appear slightly hunched, indicating a
potential discomfort or unease in discussing such topics. In terms of engagement, Heart
seems attentive to the conversation, nodding in agreement or acknowledgment at
appropriate intervals. However, there are moments when her gaze shifts towards the
window or an external point, suggesting occasional distraction or introspection.
The overall impression is that Heart is presenting herself in a composed and
socially appropriate manner, yet there are subtle cues indicating an underlying stress.
The initial observations lay the groundwork for further exploration of Heart's emotional
experiences, stressors, and coping mechanisms in further process of the assessment.

V. Psychological Testing Atmosphere

A. Test Administered
1.) Name of Tests: 16 Personality Factors (16PF) Fifth Edition, Suicide Probability Scale
(SPS), MD-5 Mental Ability Test
Date Administered: November 22-23, 2023
B. Psychological Procedures
Psychological Procedure Date Conducted
A. Clinical Interview: November 22, 2023
A structured clinical interview was conducted
with Heart to gather comprehensive information
about her background, presenting concerns,
 and contextual factors influencing her current
emotional state and academic challenges. The
interview aimed to establish rapport, explore her
personal experiences, and identify potential
areas of focus for the assessment.
B. Behavioral Observations:
November 22, 2023
Observations were made regarding Heart's non-
verbal behavior, including her body language,
facial expressions, and overall demeanor during
the clinical interview. This observational data
provided valuable contextual information to
complement the quantitative results obtained
from the 16PF.
C. Review of Academic Records:
November 22, 2023
Heart's academic records were examined to
gain insight into her educational history,
performance, and any notable patterns that
could contribute to her current concerns. This
review included an analysis of her grade
average, course load, and involvement in
academic and extracurricular activities.
D. Collateral Information:
November 22, 2023
Information was gathered from collateral
sources, including discussions with Heart's
mother, to provide a broader perspective on her
personal and family dynamics. Collateral
information aimed to corroborate self-report
data, validate concerns, and offer additional
context for the assessment.
E. Personality Assessment (16PF):
November 23, 2023
The 16PF Fifth Edition, a self-report personality
inventory, was administered to assess Heart's
personality structure. This comprehensive tool
measures 16 primary personality factors,
providing insights into her interpersonal style,
emotional regulation, and coping mechanisms.
The assessment contributes to a significant
understanding of her unique personality profile.
 F. Suicide Probability Scale (SPS):
A thorough Suicide Probability Scale (SPS)
November 23, 2023
assessment was conducted as part of the
comprehensive psychological evaluation for
Heart. The SPS is a standardized tool designed
to evaluate the risk of suicide and is particularly
crucial when there are concerns about an
individual's emotional well-being and potential
suicidal ideation. The administration of the SPS
involved a careful and empathetic approach,
considering the sensitive nature of the topic.
G. MD-5 Mental Ability Test
The IQ test provides additional information November 23, 2023
about Heart's cognitive strengths and
challenges, complementing the personality and
suicide risk assessments. Interpretation of the
IQ test result will be integrated into the overall
understanding of Heart's psychological profile.

B. Test Results, Protocols and Interpretation of Test

Test Result for 16PF
SUBSCALE RAW T Classification
SCORE SCORE
Warmth (A) 14 5 Low
Reasoning (B) 2 1 Very Low
Emotional Stability (C) 8 3 Very Low
Dominance (E) 15 6 Low Average
Liveliness (F) 14 6 Low Average
Rule-Consciousness 11 4 Below Average
(G)
Social Boldness (H) 4 4 Average
Sensitivity (I) 15 5 Low Average
Vigilance (L) 14 7 Average
Abstractedness (M) 15 8 High Average
Privateness (N) 19 8 High
 Apprehension (O) 17 7 Average
Openness to Change 19 6 Low Average
(Q1)
Self-Reliance (Q2) 12 7 Average
Perfectionism (Q3) 18 8 High Average
Tension (Q4) 14 6 Low Average
Interpretation:
The 16PF results highlight a unique combination of personality traits in Heart.
Notably, she exhibits strengths in traits associated with Abstractedness, Privateness,
and Perfectionism, indicating a preference for intellectual exploration, a need for privacy
and a need to strive for flawlessness and perfection accompanied by critical self-
evaluations.
However, areas of concern include very low scores in Abstract Reasoning,
Emotional Stability, and low scores in Warmth and Social Boldness. These suggest
potential challenges in abstract way of decision-making, emotional regulation, and
assertiveness in social situations. However, it is important to note that the classification
labels are relative to the normative population.
Test Result for SPS
SUBSCALE RAW SCORE WEIGHTED SCORE Classification
Hopelessness 39 78 Severe
Suicide Ideation 32 77 Severe
Negative Self- 12 51 Moderate
Evaluation
Hostility 21 76 Severe
Total Weighted 104 77 Severe
Score/ Average
Interpretation:
The Suicide Probability Scale (SPS) results revealed high scores across key
aspects. Heart exhibits notable hopelessness (39), suicide ideation (32), and hostility
(21), adding to a significant complete weighted score of 104 and an average of 77. This
highlights a significant suicide risk, requiring immediate attention and intervention. The
combined severity across these subscales stresses the urgency for safety planning,
ongoing monitoring, and coordinated effort with mental health professionals to figure out
a right treatment plan addressing the factors contributing to the increased risk.
Test Result for Mackenzie Davey 5 Mental Ability Test
RAW SCORE PERCENTILE CLASSIFICATION
29 65 Average
Interpretation:
Heart's result in the Mackenzie Davey 5 IQ Test, yielded a raw score of 29 and a
percentile rank of 65. This indicates that Heart's cognitive abilities fall within the average
range compared to the general population.

VI. Diagnostic Impression and Interpretation

Heart presents with a complex combination of emotional distress and potential
risk factors, as evidenced by the information gathered from various sources.
Heart displays symptoms consistent with a mood disorder, including extreme
sadness, mood swings, and changes in sleep patterns and appetite. The ongoing
financial crisis and parental conflicts further contribute to her emotional distress. The
emerging challenges within Heart's family dynamics, suggest the possibility of a
significant problem in adjustment.
The results from the Suicide Probability Scale (SPS) indicate a significant risk of
suicide. High scores in hopelessness, suicide ideation, and hostility emphasizes the
urgent need for intervention and close monitoring to ensure her safety. In her 16PF
results it has reveal a complex personality profile. Strengths in traits associated with
intellectual exploration, privacy, and perfectionism are noted. However, challenges in
abstract reasoning, emotional stability, warmth, and social boldness suggest potential
difficulties in decision-making, emotional regulation, and assertiveness in social
situations.
Moreover, considering the MD-5 Mental Ability Test result, with a raw score of
29, a percentage of 65, and a classification of 65, it suggests a moderate level of mental
ability. This information can be valuable in understanding Heart's cognitive functioning
and may provide insights into her overall psychological well-being.

VII.) Recommendation
In order to best serve Heart’s needs there are several areas that may be targeted
for intervention:
Immediate Safety Measures: Given the high suicide risk, immediate safety measures
are important. Collaborate with mental health professionals to develop a safety plan,
involve family support, and establish regular monitoring to mitigate the risk.
Mental Health Education and Support: Provide psychoeducation to Heart and her
family about mood disorders, adjustment difficulties, and the impact on mental health.
Offer support and normalize seeking help from mental health professionals.
Individual Psychotherapy: Initiate individual psychotherapy to address Heart's
emotional distress, enhance coping strategies, and promote emotional regulation.
Cognitive-behavioral therapy (CBT) may be particularly beneficial.
Family Therapy: Engage the family in therapy to address the impact of the financial
crisis and parental conflicts. Strengthen communication, problem-solving, and coping
skills within the family unit.
Academic Support: Collaborate with the university to provide academic support, such
as counseling services and accommodations, to help Heart manage her academic
workload and performance.
Collaborative Care: Facilitate collaboration between mental health professionals, the
university counseling center, and community resources to ensure a comprehensive and
coordinated approach to Heart's care.
Regular Follow-Up: Establish a regular follow-up schedule to monitor progress, assess
safety, and make necessary adjustments to the treatment plan.

Prepared by:

Heartche L. Selibio, Rpm, Rpsy

Noted by:

Clinical Psychologist