Clinical Report Writing Format
Psychodiagnostic Report (Title) (Adult Psychodiagnostic Report/ Child Psychodiagnostic
Report)
Identifying Information:
Client’s Name: XYZ
Father’s Name: ABC
Gender:
Age:
Assessment Date: (all date of assessments)
Examiner:
Referral Source and Presenting Complaints: Write Verbatim in table form with no table
borders.
Clinical Interview: Following sequence will be followed without heading
Presenting Problems (nature of problems, precipitating event, patient’s feelings and
thoughts about the problem)
History of Problems (duration of present problem, changes in nature, intensity, and/or
frequency of problem over time, prodromal manifestations, other past problems of a
psychological nature, No. of attacks)
Prior Treatment (Details of treatment sought for presenting problems and from whom:
When the treatment was sought? Duration of treatment? Nature of the treatment methods:
Name, Dosage: ECT, Faith Healing, etc. response to the treatment including adverse
reactions or side effects if any):
Medical History (most recent physical exam: date and results; current medications; health
condition since childhood including details of serious illness/disabilities suffered and
milestones of child surgery undergone; eating and sleeping if remarkable and any change
of same; use of stimulants, alcohol and drug):
Family History (migrations, births, marriages serious illnesses, deaths, jobs of earning
members, relationship with family members):
Family Psychopathology (nature, history and treatment of mental disorders on members
of the patient’s family:
School History (marks/divisions obtained, school changes, school problems, relationships
with peers and teachers, extra-curricular activities):
History of Friendships (nature and extent of relationships, recreational activities, degree
of religiosity, sexual history – premarital, marital and extramarital sexual relationships):
Orientation: (time, place and person):
Somatoform (conversion, hypochondriasis, and other somatic complaints)
Test administration:
Neuropsychological Screening Tests (e.g.: BGT, QNST)
Intelligence Tests (e.g.: SIT, TONI, WISC, SPM, CPM etc.)
Psychopathology Tests (Objective Tests e.g.: CARS, ADHDT etc.)
Projective Tests (e.g.: RISB, HFD/HTP, CAT TAT etc.)
Behavioral observation:
Following sequence will be followed without heading
Appearance
Interaction/communication (Verbal and non-verbal)
Behavior during test
Psychological evaluation
Test scoring according to the sequence of test administered
Table 1. name of test
Description of scoring
After table qualitative interpretation
Tentative diagnosis
Prognosis
Conclusion
Recommendation/Suggestions (recommendations for institutions in child case )
_________________ ____________________ ____________________
(Assessor Name) (Supervisor Name) (Head of Department Name)
MS Internee Internship Supervisor
Sequence of Report for Binding
1. Psychodiagnostic Report
2. Intake form Case History Sheet and Mental State Examination
3. Appendices:
Appendix 1. Log Form
Appendix 2. Test Protocols according to the sequence of test administered
Appendix 3. Therapy Protocols
Appendix 4. Case Formulation and Conceptualization
