What must an evaluation record kept by a psychologist include?

An evaluation record kept by a psychologist must include demographics and presenting problems because these elements provide essential background information that informs the treatment process. Demographics such as age, gender, and ethnicity can influence the psychological assessment and treatment. Presenting problems detail the client's issues or symptoms that brought them to seek help, serving as a foundation for diagnosis and intervention planning. Including this information ensures that the psychologist has a comprehensive understanding of the client's situation, which is critical for effective treatment.

While other aspects like payment history, insurance details, diagnoses, or personal relationships might be relevant in certain contexts, they do not constitute the core elements of an evaluation record that are necessary for ongoing assessment or treatment planning. Demographics and presenting problems are standard components that align with ethical and legal guidelines governing psychological practice, reflecting best practices in the field.