Court-Ordered Psychological Evaluation — Vasquez, Maria E.

Psychological Evaluation Signed Risk: Low

Summary

Ms. Vasquez is a 34-year-old Hispanic female evaluated pursuant to court order in connection with custody proceedings (Case No. 2026-FC-0891). She presents as psychologically stable, medication-compliant, and actively engaged in her daughter's care. Prior psychiatric history includes a brief voluntary hospitalization in 2024, with sustained recovery since.

Identifying Information

Maria Elena Vasquez, 34-year-old Hispanic female. Separated, one child (Lucia, age 7). Employed as medical billing specialist. Court-ordered evaluation per Case No. 2026-FC-0891.

Purpose of Evaluation

This evaluation was ordered by the Honorable Judge Patricia Kim to assess Ms. Vasquez's psychological fitness for primary custody of her minor child. Client was informed of the limits of confidentiality and the evaluative nature of this session.

Psychiatric History

Voluntary hospitalization (5 days, March 2024) for acute panic disorder during marital crisis. Stabilized on sertraline 100mg daily. No subsequent hospitalizations. Current treatment: sertraline 100mg daily (Dr. Okafor, psychiatrist) and weekly individual therapy.

Mental Status Examination

Appearance: Neatly dressed, appropriate affect. Behavior: Cooperative, open, appropriate emotional range. Speech: Normal. Mood: "Good — focused." Affect: Warm, congruent, full range. Thought Process: Organized, goal-directed. Thought Content: Child-centered, no delusions or obsessions. No SI/HI. Cognition: Intact. Insight: Excellent. Judgment: Good.

Parenting Assessment

Ms. Vasquez describes consistent daily routines (bedtime, meals, school preparation), active involvement in extracurricular activities (soccer coaching), cultural engagement (cooking traditional foods together), and nightly reading. She demonstrates awareness of Lucia's emotional needs and adjustment difficulties.

Psychometric Results

PHQ-9: 4 (Minimal Depression). GAD-7: 6 (Mild Anxiety). PSI-4: Within normal limits across all subscales. MMPI-2-RF: Valid profile, no clinical elevations.

Clinical Impressions

Ms. Vasquez demonstrates psychological stability, consistent medication adherence, and active therapeutic engagement. Her narrative is child-centered, and she describes age-appropriate parenting strategies, consistent routines, and emotional attunement to her daughter's adjustment difficulties. The 2024 hospitalization, while notable, was voluntary, brief, and resulted in effective treatment that has been maintained for over 18 months. There are no current indicators of acute psychiatric disturbance. Her insight into her mental health journey is a significant protective factor. Lucia's behavioral changes at school (increased withdrawal) are consistent with normal adjustment to parental separation and warrant monitoring but do not indicate inadequate parenting.

Recommendations

1. Ms. Vasquez appears psychologically fit to maintain primary custodial responsibilities 2. Continued psychiatric medication management with Dr. Okafor 3. Continued individual therapy 4. Recommend family therapy to support Lucia's adjustment 5. Collateral interviews with Dr. Okafor and Lucia's school counselor recommended to supplement this evaluation 6. Separate evaluation of father recommended before final custody determination

Report Details

Report Type: Psychological Evaluation
Status: Signed
Generated: Feb 17, 2026 at 6:29 AM
Signed By: Dr. Sarah Mitchell, Psy.D.
Signed At: Feb 13, 2026 at 9:15 AM

Diagnoses (DSM-5)

F41.0 PRIMARY

Panic Disorder (in remission)

Z63.5

Disruption of Family by Separation

Risk Assessment

1/5

Low

Risk Level

Risk Factors

History of psychiatric hospitalization (mitigated by sustained treatment adherence)

Source Session

Maria Elena Vasquez

Feb 12, 2026 — 120 min

MEV-2026-0042

AI Analysis Confidence

Diagnostic Accuracy 92%

Treatment Relevance 88%

Risk Assessment 85%

Documentation Quality 95%