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Format for Child Case Report

(1st level heading)

Summary of the Case (2nd level heading)

Complete description of the case in one paragraph starting with initials, age,

presenting complaints, no of sessions done, conclusion of all assessment tools not more

than 2 lines, management done along with techniques, outcome and any

suggestion/limitation. (It will be written on separate page).

Identifying Data

Basic demographic information of the client i.e., name, age, gender, education,

number of siblings, birth order, socio-economic status, number of sessions, institute

initials, initial date seen, last date seen etc.

Source and Reason for Referral

Reason and background of the referral (if any).

Presenting Complaints

In exact verbatim of the informant or referring person. Write in table form and give

table number & legend. Write down a Note under the table * the presenting complaints are

discussed in detail in assessment section.

Table 1

Presenting Complaints of the Client by Psychologist

Presenting Complaints Duration

He can’t concentrate 1 year

Poor on seat behavior 8 months

Note.
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Initial Observation

Client’s initials, age and class also mention summary of the activity he/she was

indulged at the time of your first interaction. Write a paragraph about his/her physical

appearance including hygiene. Also mention any specific physical features you have

observed. A brief explanation of child’s LRS (attention span, eye contact, on seat behavior,

motor functioning, comprehension, compliance and language).

History of Present Illness

The course of problem (how it started and progressed) developmental history of

problem. How the problem has developed from its beginning till now, including history of

any treatment, current level of the client’s functioning and so on. Discuss it chronologically

e.g., the child’s problem started before 6 years ago as he reported that he started showing

aggression, head banging, less social interaction…

Background Information

Personal History (3rd level heading)

Birth and Early Developmental History. Includes the birth order, history

milestone’s development, any serious injury or trauma, premorbid personality, client’s

interests (likes, dislikes), his daily schedule, best time spent. Peri, pre- and post-natal

history of your client should also be mention here.

Table 2

Developmental Milestones, Age of Achievement by the Child and Normal Age

Developmental milestone Age of achievement Normal age of

achievement
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Family History

Starting from system of family, number of family members, their info and

relationship with the person and with each other, parental occupation and education,

overall home environment, etc. make separate paragraphs for mother, father and siblings.

In case of guardians, follow the same format.

Educational History

Start this paragraph with the age the client started his schooling for the first time. In

case the schooling was started at the age of 4, 5 and 6 years or after that, tell how he used

to spend his time at home; any history of informal education: Quranic education. It

includes the information about the client’s relationship with class fellows as well as

teachers. Client’s class performance and teacher’s comments and so on.

History of Psychiatric Illness in Family

In the family (paternal or maternal both sides), state what is the attitude of family

members with that member of family and type of treatment being extended.

Premorbid Personality

Personality of the client before the illness.

Psychological Assessment

Informal Assessment

Behavior Observation

Reason and rational of behavior observation.

Clinical Interview

Mention reason and rationale of conducting clinical interview with the referral

person.

Subjective Rating of the Client

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Mention reason and rationale of conducting clinical interview with the referral

person, also mention its reference.

Table 5

Pre-management Rating of Client’s Problematic Behaviors by the

Parent/Teacher/Psychologist

Presenting Complaints Pre-Management rating (1-10)

Standardized tests used with their rationale, (each test should be reported in terms

of results, quantitative and qualitative interpretation and conclusion) and drawings. At the

end of all assessment tools give conclusion in one paragraph.

Baseline Charts of Problematic Behaviors

Formal Assessment

Quantitative Analysis

Add table along with table number and legend.

Qualitative Analysis

Provisional Diagnosis

According to DSM V TR

Code, Disorder name, specifier (eg (F32.1) Major Depressive Disorder, moderate)

Prognosis

Mention the chances of betterment in the functioning level of client in the light of

factors discussed in case formulation.

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Case Formulation

Provide an understanding and psychological explanation of the case, symptoms and

etiology keeping in mind predisposing factors e.g. genetic predisposition, precipitating

factors e.g. developmental delays, parent’s neglect, malnutrition, trauma or accident,

maintaining factors, the factors that may not have been involved in the initial problem

developing, but are helping to maintain the problems e.g. parental neglect, problem in

school, client comprehension and compliance, protective factors (the factors that can help

the person cope or act as resource e.g. client’s temperament, intelligence or any other

strength, family affection and encouragement, external support system which reinforce

competence) or any relevant researches according to client’s problem. The case

formulation should give a direction about how problem could be managed.

4 Ps in pictorial form

Management Plan

Table of short-term, long-term goals and therapeutic techniques.

Summary of Therapeutic Intervention

Rationale of each technique and how it was used with the person.

Therapeutic Outcomes

Pre and Post Management Rating in a table form.

Table 6

Pre-management Rating of Client’s Problematic Behaviors

Presenting Pre Management Rating Post Management Rating %

Complaints (1-10) (1-10) Change

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Limitations

State what were the short comings that you had to face in order to achieve goals of

the therapeutic intervention? `

Recommendations

Give further suggestions for the client that would help in dealing with the problem

in future.

Session Report

Format of Session Report is as follows:

Session 1 Date:

Mention the following points in session report:

Time duration

Behavioral observation

Session goals

Session outcome

Individualized Therapy Program (ITP)

Bio data

Strengths and weaknesses of the clients

Strengths Weaknesses

Task Analysis

Task:

Areas:

Rationale:
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Steps:

Task Material Goal Technique

References

Should write according to APA 7th edition

Appendices (at the end of each report)

Baseline Charts (if applicable)

Copy of administered assessment tools

Sample Task Analysis and

Sample Daily Performance Record Form

Sample worksheets etc. (few only)