Sample Outline of a case Report

I. Identifying Information
A. Name of Client
B. Sex
C. Age
D. Social Status
E. Ethnicity
E. Place of Origin
F. Date of evaluation
F. Religion/Occupation
G. Educational Attainment
H. Date of Test/Interview
 II. Reason for Referral (Brief Statement of the problem/psychopathology based
on the assigned theory)
III. Assessment procedures (the assessment/data gathering procedure)
IV. Case Background/Personal History, Formulation of personality
Structure, dynamic, determinants and development - personal, social, academic, vocational,
mental health, medical client’s history)
A. Information relevant to clarifying the referral question
B. A statement of the probable reliability/validity of conclusions
V. Physical and Behavioral Observations(Observations during interview interview)

VI. Summary of impressions and findings

A. Cognitive (description)
B. Affective and mood levels(description)
C. Interpersonal and Intrapersonal level/Defense Mechanisms
 Primary interpersonal and intrapersonal conflicts, and their significance.
 Interpersonal and intrapersonal coping strategies (Including major defenses)

VI. Diagnostic impressions

B. The most probable diagnosis

VII. Recommendations (the psychotherapy-based on the assigned theory)