How to write a Psychological Report? Writing Sample/ Clinical Psychology Report Format Sample

Psychological Report Writing Sample/ Clinical Psychology Report Format Sample 

In the previous post, we learned how to write a clinical report of the client and its basic components now we apply all those learnings here. link of the previous post "Psychological Report Writing / Clinical Psychology Report Format

we learned for example how to prepare a case history of a client or how to write a clinical psychology report. the report format is given below with a sample case. 

Case History Sheet

Name of the patient: CLIENT NAME                        Gender: female

Date of birth:      1997                                                Age: 23

Marital statuses: Married                                         Race: N-A

Religion: Islam                                                      Appearance: Clean

Education: educated, Matric                                Occupation: Housewife

Siblings: 3        Male: 2          Female: 1               Birth Order: 3

Children: not yet.                                                    Family structure: joint family                      Language: Urdu.                                                     Intake by:  YOUR NAME

Informant: Subject Herself                       Intake on Date: 4 November 2020.

Presenting Problems

            The client reported that after one weak of her marriage she felt her headache, lost her senses, and after that her hands and feet turn around, she listened to the voices of people around her but could not respond to them. She also said that sometimes she feels that someone is calling her but she cannot see the person (auditory hallucinations). According to her she feels pressure on her mind and thought someone is standing behind her and observed her and also thought that something bad is going to happen (persecutory delusions). She reported that she also has nightmares (see weird shapes of a human).

The subject reported that she lived in (CITY NAME) and two months ago she got married to her cousin. Her husband’s family lives in (CITY). So after marriage, she has to move here. Her parental family came with her to (CITY) and spent two weeks with her and then go back to Karachi. After their return, she felt the headache and heart palpitation. And then lost her consciousness. her hand and feet turn around (it was the first attack). After recovery from attacks, she feels body pain. 

Precipitating event of a problem is a marriage of a client. Two months passed to her married life.

History of Problem 

The client reported that after marriage she suffers from headaches followed by loss of consciousness. She feels heart palpitation, has feelings that something bad is going to happen. At the start, she had two such attacks in a week. She reported that the frequency and intensity of attacks decrease after the use of medicines prescribed by a doctor.

She reported in past she did not have such problems or psychological illnesses. No attack but she had persistent thoughts that she is being observed by someone.

Currently, her appetite decreases. Still have sleeping problems. She can maintain hygiene. 

Prior Treatment 

Subject reported that at the start her in-laws thought that she has some possessions because of which her hand and feet turn and she goes into an unconscious state. They took her to moulvi for spiritual healing, but her condition did not improve. After that, her husband took her to (HOSPITAL NAME) for medical treatment. It was her second visit to the doctor. At the first visit, the doctor prescribed her anti-depressants because of which she feels better no of attacks decreases and feel relieved from the body pain and headache. Side effects of anti-depressants were nausea, vomiting, and dry mouth.  

Medical History

The subject reported that she has no medical history, no serious illness. Because of nightmares, her sleeping disturbed, she said “I wake up after a nightmare and cannot sleep again”. She uses sleeping pills. Her appetite decrease. Do not use any type of stimulant.

Family History 

The client's family is a joint family. Live with her in-laws (mother and father-in-law, two brothers-in-law, and one married sister-in-law). She has 3 siblings, two brothers, and one sister and she is on the first number among her siblings. Her father is a security guard and her younger brother works in the family. Her youngest sister is 15-year old. 

A client reported that her mother has skin and blood pressure issues. She is very attached to her. Before marriage, she spent more of her time with her mother. No death in the family. The family atmosphere is good. She has good relations with her family. The client's financial status is also good.

School History 

The subject reported that she was a good student. She did her matric from the government school Karachi. She had good relations with friends and teachers. She could not continue her studies because of her mother's illness.

Work History 

She is a housewife.

History of friendship 

The subject reported that when she was in school she had good peer relationships. she is religious. She did not have a sexual history, spent leisure time with family especially with her mother.

Psychosomatic

She reported that after attacks she suffers from headache, body pain, and heart palpitation. And also after the use of prescribed medicines have dry mouth, nausea, and vomiting.

Addictions 

Use only sleeping pills.

Family psychopathology

The subject reported that in her family there is no mental disorder. 

Personality Traits 

She does not like to meet people (introvert) and has a fear that something bad is going to happen (schizotypal). She is avoidant and passive-aggressive.

Interview Behavior 

At the start she was anxious but she cooperates with me to give answers to question and was disinhibiting. 

Orientation 

The subject was not aware of time. The subject was aware of the place. When I asked about the name of the place she replied “it is a mental hospital “NAME”. She knows his name when she was asked about her identity she told me her name.

The subject scored 23 out of 30 on the mini-mental status examination. This indicated that subject is normal

Sleep 

The subject reported that she could not sleep. She has nightmares because of which she wakes up at night and cannot sleep again. 

Attention 

The subject listens to every question carefully and responded to every question in a good way. Her concentration was good. And she knows school memories and other specific events of her life so her memory is well as good

Perception 

She reported that after her this condition she feels that someone is standing behind her and observe her and also something bad is going to her (persecutory delusions). After medication intensity of such feelings decreases.

Thoughts 

 The subject reported that she had unusual thoughts that someone is standing behind her and observe her and also something bad is going to happen with her (persecutory delusions).

Affect 

The subject reported that she feels depressed. And sometimes want to cry without any reason.

Behavior 

During the interview, the subject was restless 

Mannerism and posturing 

The subject did not change body posture, mannerism was good, show no unusual gestures, and rub her hand repeatedly after some time.

Diagnosis 

The subject is diagnosed with Separation Anxiety Disorder 309.21 (F93.0).