University of Management and Technology

Department of Clinical Psychology

We train professionals

Case Report Format

Guidelines
 Case Report Format

General Requirements: APA 7th edition should be followed including

 Case report should be written in Times New Romans, 12 font size

 Insert page number at the right top of the page

 Write case number at the left top of the page by using Header

 Indent each paragraph with line spacing 1.5

 Heading levels should be according to APA 7th Edition

 Margins are 1.5 inches from the left edge and 1 form the other three edges,

 Must number each table and figure separately for each case study

 Give appropriate legend to each table and figure

 Give appropriate reference of each technique and assessment tool.

 Give reference in text and in Reference List according to APA 7 th Edition

specification

Initial Pages (Format Attached – Appendix A)

o Title page

o Case report completion certificate

o Declaration

o Acknowledgments

o Table of Content
 Case Report Format

 Summary of the Case. (complete description of the case and number of sessions in
one paragraph) (Identifying Data – initials, age, gender, grade, presenting complaints,
assessment techniques, summary findings, management, outcome, total number of
sessions)
 Identifying Data. (Initials, gender, age, grade, number of sessions, initial date seen,
last date seen, school)
 Reason for referral. (e.g. Source of the referral: the class teacher, subject teacher)
self-referral
 Presenting Problems. (verbatim by the teacher and by the child)
 Initial Observation. (appearance (uniform, nails trimmed, etc.), posture, speech, eye
contact, behavior on initial contact, child’s own perception of the referral)
Developmental History of the Problem
 Source of information.
 What is the problem, when it started, how it maintained and what is the current
level of child’s problem.
 The course of the problem.
Background information
 Personal history (child’s daily activities, current routine, hobbies, likes and dislikes,
free time activities)
 Family history. (family system, number of family members, father age, father
education, father occupation, mother age, mother education, mother occupation,
father-mother relations, any significant information, number of siblings, family
environment, interaction with family members, genogram)
 Educational history (schooling started at what age, school performance, change of
school and reasons, interaction with teachers and class fellows, teaching
methodology, favorite subject, information about tution).
 Provisional formulation. Overall conclusion so far including brief summary of risk
and protective and maintaining factors of the problem.
 History of medical illness (if any)
 Assessment. (what, why and how), outcome, general conclusions, reinforces
identified, clinical interview, baseline chart, cognitive assessment, subjective ratings
of the problem, School Chlidren Problem Scale (SCPS) etc) add qualitative and
quantitative interpretation of the test scored used for assessment.
 Summary of assessment results: it includes overall summary
 Case formulation. Formulate your case according to bthe Bio-Psycho-Social
Factors. (summarize all the contributing predisposing, precipitating, maintaining, and
protective factors that lead to the current problem, strength and weakness of the
child). Provide an understanding and psychological explanation of the problem.
Should include predisposing factors (e.g. genetic predisposing factors),
precipitating factors (e.g. parent’s death, conflict in the family, loss of social
support), maintaining factors (e.g. the factors that may not have been involved
initially in the development of the problem, but help in maintaining the problems (e.g.
parental neglect, problem in school, child’s personal motivation), protective factors
(the factors that can help the child to cope with the problem e.g. child’ own easy
temperament, family bonding)
 Summary of case formulation (summarize the child’s problem in pictorial manner)
 Intervention plan (overall planning of assessment on the basis of observation and
assessment tools)
 Intervention strategies. (what, why, how) (short and long term plans, rationale of
each technique and how it was used)
 Outcome. (pre and post assessment with the help of table & histogram)
 Limitations. (what are the limitations you have faced in order to deal with the child’s
and achieving short and long term management goals)
 Recommendations (further suggestions that might help the child in future in dealing
with the childs, follow up)
 Session reports.(session by session report with goals, activities, child’s behavior and
outcome)
 List of references (as per APA 7th edition format for each case report separately)
 Appendices (copy of referral form, base line charts copies of administered tools ,
copy of activities carried out in the sessions, copy sample of worksheets, and
additional material used in assessment and management)
 Preliminary Report
(Should not be more than two pages and signed by the trainee and the Supervisor)

Department of Clinical Psychology

School of Professional Psychology
University of Management and Technology
We train professionals
Preliminary Report I
Identifying Data
Name:
Age:
Gender:
Grade:
School:
Total number of sessions:
Initial date seen:
Last date seen:
Source and Reason for Referral

Presenting Problems
(both tables)

Initial Information
(Initial observation and developmental history of the problem)
Initial Assessment
(Only in bullets)
Preliminary Findings
 (Summarize main findings)
Provisional Formulation

Future Plans
Assessment
(only name of the assessment techniques)
Management
(only name of the management techniques)
 Department of Clinical Psychology
University of Management and Technology
We train professionals
Discharge Report I
Identifying Data
Name:
Age:
Gender:
Grade:
School:
Initial Date Seen:
Last Date Seen:
Source and Reason for Referral

Presenting Problems
Table 1
Presenting Complaints and their Duration as Reported by the Teacher
‫دورانیہ‬ ‫شکایات‬

Table 2
Presenting Complaints and their Duration as Reported by the Child
‫دورانیہ‬ ‫شکایات‬

Initial Information
(Initial Observation & Developmental History of the Problem)
Findings
 (Summary of Assessment Results)
Provisional Formulation

Management
(Summary of management in running text, intervention techniques with goals)
Current Status
(Share the current status in each goal)
Suggestions
Teacher
(in running text)
Student
(in running text)
Parents
(in running text)
 Department of Clinical Psychology
University of Management and Technology
We train Professionals

Group Session

Date:

Time Limit:

Group Title

Rationale: The major reason and purpose of the group

Objectives: Mention the major goals

No. of Group Members

Group Leader:

Group Rules: Report simple and clear rules given to the members.

Activities: Report all the activities details used during the group.

Material:Mention the material used in the group session.

Outcome: Here mention the overall group performance.

Limitations and Recomendations.

 Department of Clinical Psychology
University of Management and Technology
We train Professionals
Placement Observation

Introduction

Briefly introduce the place, find out an important fact/information.

Strengths:

Strengths of the place, keep in mind its environment, session rooms, classrooms,

teacher’s cooperation, what were the positive things in this place that helped you to

achieve your goals regarding your client’s services provided to the trainees and school

children or any other etc etc etc.

Weakness

What else they can do to improve their services,regarding needs of the children

e.g First u think yourself than will tell you☺

Limitations

What problems u faced while dealing with your client (during assessment, management,

history taking,dealing with teacher, what were the factors that hinder the

counsellingprocess)
 Portfolio

Clinical Case Studies (Counselling)

Participant’s Name

XYZ

Participant ID

ABC

Supervisor

Ms. Sana Fatima

__________________________________________________________________

Department of Clinical Psychology

School of Professional Psychology

University of Management and Technology

Lahore

2023
 DECLARATION

I, XYZ, Roll no. ------- student of BS Clinical Psychology, Session 2020-2024

hereby declare that the matter presented in this Portfolio is my own original work.

Dated: Signature of the Trainee

 PORT FOLIO COMPLETION CERTIFICATE

It is certified that the work contained in this Portfolio has been completed by

Ms. XYZ, Roll no S2021146002, under my supervision.

Dated: Supervisor

Ms. Sana Fatima

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