Psychiatric Evaluation Examples

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(based on an asylum evaluation conducted by Dr. Kathleen Allden, M.D. in November 2000, Boston, MA, USA)

I. Case Information

Name: Mr. __

Birth Date: x/xx/68

Birth Place: __

Gender: male

Clinician’s Name: Kathleen Allden, MD

Not needed as client speaks English

Exam Requested by: Attorney Jane Doe

Subject Accompanied by: Attorney Jane Doe (first appointment only)

II. Clinician’s Qualifications [deleted]

Attached is my curriculum vitae.

I have personally examined this individual and have examined the facts recited in this written report. I believe all statements to be true. I would be prepared to testify to these statements based on my personal knowledge and belief.

Background Information

Mr. __ is a 35 year old married man from [country A]. He came to the United States seeking asylum in February 2000. His wife and three children, ages 14, 10 and 5 years, are in a refugee camp in [country B], along with his mother and sister.

Summary of Collateral Sources

Draft Application for Asylum and Withholding of Removal supplied by his attorneys

Methods of Assessment Utilized

Clinical interviews

History of Torture and Ill-treatment

Mr. __ reports that he came to the United States in February 2000. He is seeking asylum because he feels it is not safe for him to return to [country A]. He says that in 1990 he was at his parents’ home when __ rebel forces attacked the house. He believes that his family was targeted because of his father’s job in the government, and because they are of the __ ethnic group. He was at home with his father, mother and sister when the house was attacked. Mr. __ and his family were taken to a rebel camp. He reports that the rebels forced him to hold his sister down while they gang raped her. Also, he was forced to watch as rebels tortured his father and cut off his limbs one at a time. He reports he was forced at gunpoint to hold his father down while they did this. He believes the rebels killed his father because at the time he was an officer in the government.

After a period of time, his mother and sister were able to leave the camp but Mr. __ says he was taken to another camp where he was burned and cut on the right arm and put in a pit. While in pit, the rebels urinated on him, threw dirty water on him and beat him. He remained in the pit for a long period of time. Conditions were filthy in the pit and his right arm became very infected. Mr. __ recalls becoming ill and coughing up brown sputum. While he was still in the pit, [country A] soldiers overtook the camp and freed him. He said that they could tell that he was not one of the __ rebel forces soldiers because it was obvious that he had been severely mistreated by them. For this reason, his life was spared at that time. He reports then being taken to the border where he escaped to [country B] and was able to reunite with his mother and sister.

During the years 1990-96, Mr. __ reports that there were many factions fighting in [country A]. He did not go back to [country A] until 1996 when there was a cease-fire. He went to check on the family’s property but found that the family’s house had been burned. He remained in [country A] where he participated in the presidential campaign of __, and was physically beaten by opposing political forces that were on the same side that had originally attacked his home and killed his father. The soldiers took him to a prison. Mr. __ and his family are members of the __ tribe. He reports that he and other __ tribe prisoners were taken away to the forest to be killed. The soldiers shot at the group of prisoners as the prisoners ran away. An unknown number were killed but Mr. __ escaped.

He went to live in barracks in an area where other __ tribe people were staying because they felt they might be safe there. In 1998, when __ rebel forces attacked this area, many people were killed. Soldiers attempted to arrest Mr. __. He believed they would take him away and kill him. He managed to escape and ran to __ peacekeeping base where other __ tribe people as well as other civilians had fled. __ peacekeeping base personnel helped Mr. __ and others flee the country by arranging for flights from an airbase. Mr. __ was flown to [country B] where he joined his mother and sister in a refugee camp.

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Q&A

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How do I schedule a mental status evaluation? | Yahoo Answers

John ... start by seeing your regular physician. They will give you a full blood workup checking for things like blood sugar disorders and glandular problems. If they don't find anything, then see a psychiatrist for diagnosis and treatment. There are very good medicines today to treat most mental disorders and well as therapy once the medication(s) take effect. Take care of yourself by eating healthy, doing cardio exercise and getting quality sleep, which are also needed for positive brain chemistry. Chip

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