Case Report

OUTLINE OF A CASE STUDY REPORTI.
Identifying Information
Name of the Client
Sex
Age
Civil Status
Educational Attainment
Religion
Date of the Evaluation
II. Reason/s for ReferralIII. Assessment Procedures
Testing Behavior
Psychological Tests Administered
Mental Status Examination
IV. Background of the Client
Adaptation in life situationsWhat are the major tasks in the client’s life (work, school, family)
andhow well is he functioning? Does he seem to be at or below optimum?
Symptomatic Behavior
From the client’s standpoint, what is troubling him? What are his“presenting symptoms?”
•
As viewed by concerned others, family or coworkers, whatdeviant or disturbed behaviors does the cl
ient show? Whatbothers them?
From the perspective of the assessing clinician, what

evidenceis there pf psychological disturbance? Are there thoughtdisorders or failure of reality testin
g? Are negative emotionsoverly strong, uncontrollable, or painful? Anxiety? Depression?Are
distressing conflicts visible? Obsessive thoughts?
Specificdysfunctions, e.g., failures of memory, inept problem-solving,concrete thinking?
Motivation for clinical care and preconceptions about mental healthWhat does the client expect will
happen in the clinic? Why did hecome? What is hoped-for outcome? Symptom relief? More
effectivefunctioning? Personality change? Change in distressing externalconditions? What does
being a “patient” mean to him? How does heview mental illness, mental health? Is he
psychologically minded?
Appearance and behavior in the clinicIs he anxious? Guarded? Trusting? Uncooperative and
resistant?
V. Social Determinants and Current Life Situation
FamilyWhat are the relationships between patient and spouse, parents or children? How does the
present family system work? Is it like or unlikethat of ‘family origin?”
Education and workSchool and work history. Is the client satisfied with his workachievements,

income, and conditions of work? Is leisure available?How is it used?
Social ecologyIn what kind of community (physical and social) does the client live? Isit “home”
or alien? Does he identify his welfare with community goals?
Does he participate in community affairs, work for communityimprovement?
Is the environment crowded, noisy, safe, and ugly?Does he commute or live close to work? Are desir
ed facilitiesavailable?
VI. Personality Development
Here the question is “How the personality did come to be?” the answer necessarily involves analysis
of early life experiences, relationships to significantothers, parents and peers. The critical
identifications throughout life and
major learning experiences. The history and sequence of social and interpersonalinfluences on the
person. Of particular importance is the way in which the patientcoped with successive
developmental tasks. What alternatives were available tothe client? How did he withstand new
experiences and challenges? Did he holdto safe and established modes of behavior? Could he take
new roles?
VII. Summary of Impressions and Findings
(based on the assessment toolsand the personal background of the client)
Cognitive Level
Current intellectual and cognitive functioning (e.g. ideation,intelligence, memory, perception )
Degree of impairment compared to premorbid level
Probable cause of impairment ( by end of this subsection,

theevaluator should know whether the client has a thoughtdisorder, mental retardation, organicity)
Affective and Mood Level
Mood, affect at present – compare this with premorbid levels
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Degree of disturbance ( mild, moderate, severe)
Chronic VS Acute nature of disturbance
•
Lability – how well the person modulate, control affect withhis/her cognitive resources? ( by the end
of this subsection, theevaluator should know whether there is a mood
disturbance,what the client’s affects are and how ell controlled his/her emotions are?
Interpersonal- intrapersonal Level
Primary interpersonal and intrapersonal conflicts and their significance
Interpersonal and intrapersonal coping strategies (includingmajor defense)
VIII. Diagnostic Impression
Use the multi-axial system of making diagnosis
IX. Recommendations
Desired OutcomesWhat qualities pf the client and/or his situation requires change if thepatient is to
function in a more effective and comfortable way? Whatare his major growth needs which could
provide goals for therapeuticintervention?
Possible Interventions
Environmental and social. Can the client’s life conditions bechange din ways to reduce stress and

facilitate growth? For example, change of home living conditions, taking leave
fromschool, new job, etc. Can counseling be done with relevantothers, e.g. parents or friends, who
might change their impacton the client? Might new social activities be of benefit, perhapsin the
conjunction with people with similar problems?
Psychotherapy. Might psychotherapy be helpful? Of what sort,with what kind of therapist, for how
long, to what goals? Shouldit be individual, group, or family? Might other forms of psychological
intervention be useful, instead of or in addition
topsychotherapy; e.g. vocational or educational counseling,occupational therapy, music, dance or
other activities?
Other therapeutic interventions. Is hospitalization necessary?Are drugs required? Which? For what
purpose?
X. SignatureAPPENDICES
Include all the test protocols, profile sheets of the test and anyparaphernalia utilized in the conduct

of the case study
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OUTLINE OF A CASE STUDY REPORTI.

Name of the Client

Date of the Evaluation

II. Reason/s for ReferralIII. Assessment Procedures

Psychological Tests Administered

Mental Status Examination

IV. Background of the Client

From the perspective of the assessing clinician, what

V. Social Determinants and Current Life Situation

Education and workSchool and work history. Is the client satisfied with his workachievements,

VI. Personality Development

VII. Summary of Impressions and Findings

(based on the assessment toolsand the personal background of the client)

Current intellectual and cognitive functioning (e.g. ideation,intelligence, memory, perception )

Degree of impairment compared to premorbid level

Probable cause of impairment ( by end of this subsection,

Affective and Mood Level

Mood, affect at present – compare this with premorbid levels

You're Reading a Preview

Upload your documents to download.

Become a Scribd member to read and download full documents.

Start Your 30 Day FREE Trial

Degree of disturbance ( mild, moderate, severe)

Chronic VS Acute nature of disturbance

Interpersonal- intrapersonal Level

VIII. Diagnostic Impression

Use the multi-axial system of making diagnosis

Environmental and social. Can the client’s life conditions bechange din ways to reduce stress and

Include all the test protocols, profile sheets of the test and anyparaphernalia utilized in the conduct

Upload your documents to download.

Become a Scribd member to read and download full documents.

Start Your 30 Day FREE Trial

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