Case One

Biodata
Name:
Age:
Gender:
Education:
Birth Order:
Marital Status:
Occupation:
Fathers Status: Alive/dead (occupation)
Mothers Status: Alive/dead (occupation)
No. of Siblings: __ alive (__ brothers, ___ sisters)
No of Children: __ (__ son, __ daughters)
Spouses Status: Alive/dead (occupation)
Date and Place of Assessment:
Reason for Referral
Why the client came and symptoms they said they were having
Presenting Complaints
The client has been suffering from the above mentioned complaints for the last 6
years.
According to the client,
verbatim
 Following symptoms have been observed according to DSM 5 which started soon
after she started taking contraceptive medicines:

A
B
C
Family History

Past Personal History

History of Present Illness

Premorbid Personality
Before the illness started, the client was _______... activity, behavior, personality,
relationships with other people, sleep, diet, social life, etc.
Psychological Assessment
Behavioral Observation
Physical appearance, behavior, actions, state of mind, way of talking, eye contact,
rapport, cooperative or not, way of answering, way of talking, reaction to tests, tone, speed of
talking, gestures, overall the client seemed ___...
Following tests were administered for the psychological assessment of the client:
test name
test 2
On the (test name), the client obtained a score of ____ which indicates that ____.
On the (test 2 name), the client obtained a score of ___ which indicates that ____.
Case Formation
PARA 1: Brief intro, age, gender, socioeconomic status, symptoms
PARA 2: What happened and what caused it with reference. Eg. Depression caused
by imbalance of neurotransmitters and as this this person said, (last name, year)
Tentative Diagnosis
(code) name of disorder and specifiers
Therapeutic Suggestions
How the client can treat their disorder.
Therapy and why and how it would be affective
 Eg. CBT will be effective for treating negative thinking.
Prognosis
Chances of recovery, cooperative or not, personal motivation, prognosis is good, not
good, satisfactory, unsatisfactory, etc.

Sessions Report
Session 1
(Whatever you did in the first session)
Session 2
(Whatever you did in the second session)

Limitations
Limitations, what you couldnt do and why
E.g. Multiple tests could not be administered because