Format of Clinical Internship Report

While doing inrenship in clinical setting, please keep the following instructions in
mind:

 Take cases of two clients for report writing

 Preferable one female and one male client above the age of 18 years.
 Please take the cases of clients with neurosis and not from the category of
severe mental disorders.

Prefatory Parts

Title Page

The title page of the report will include:

a. The names of the undertaken cases

b. The name of the internee, Student ID and session
c. The submission date of the internship report
d. Name of the University
e. VU logo

Dedication (Optional)

If you want to dedicate your work to someone, you may write the dedication note under this
section of your internship report.

Acknowledgement

In this section you acknowledge the help and support of all the people who helped you in
completion of your internship and internship report e.g. the library staff, course instructor, family
or any other person.

Executive Summary

An executive summary previews the main points of an in-depth report. The executive summary
contains enough information for a reader to get familiarized with what is discussed in the whole
report without having to read it in full. It can be called as micro image of the report. Everything
important that you have done, discovered and concluded should be mentioned but briefly and
concisely.
Letter of Undertaking

You are required to fill in the Letter of Undertaking provided in the ‘Download’ section of the
course VULMS and attach here the scanned copy after signing it.

Scanned Copy of Internship Completion Certificate

Attach the scanned copy of your (original) internship completion certificate provided by the
organization.

Table of contents

List the important headings and sub headings in the report with page numbers. Also make a
separate list of tables and figures in the table of contents if you have used any.

For collecting case studies and writing your clinical report, you have to follow a proper
format that may include the following sections:

Background Information/ History:

The first section of your report will present your client’s background including,
IDENTIFICATION FACTORS such as name, gender, age, education, birth order, no. of
siblings, marital status, no. of children, occupation, monthly income, date of admission,
informant.

Main reasons for referral:

The client was referred to the trainee Clinical Psychologist by the Psychologist for psychological
assessment and management of the problem.

Presenting complaints:

As reported by the client he/she had

Presenting Complaints Duration (in weeks/months/years)

Note: You have to give presenting complaints in clients verbatim. Also mention if it were by
some informant.
 History of Present Illness

In history of present illness, you are required to write the client’s problem. When the
problem/illness was started? What are the predisposing factors? Which precipitating factors
trigger the problem? For how much time; the client experienced such problem/ illness? Which
was the factor that maintains that problem/illness? Keep one thing in consideration that a
sequence must be maintained while discussing the client’s problem.
Family History:

Father:

Alive/dead: Education: Occupation:

Cause of death: Physical health:

Any psychiatry problem: _____________________________________

Personality:

Nature of relationship with patient:

Relationship with wife:

If strained why/cause:
_______________________________________________________

Mother:
Alive/dead: Education: Occupation:

Cause of death: Physical health:

Any psychiatry
problem

Personality

Nature of relationship with client: Relationship with

husband:
If strained,
why/cause:

Siblings:

Total No: Brothers Sisters

 Client Birth order

Physical health Relationship with siblings

If strained, why/cause:

Overall family history: _______________________________________________

.
Personal History:
 Birth (normal or c-section, any complications faced by mother before pregnancy and after
child delivery)
 Developmental Milestone (such as, speech, crawling, walking etc.)
 Physical health/ Medical history (e.g. pneumonia, jaundice, hay fever etc.)
 Traumatic experiences (due to psychological problem, sexual assault etc.)
 Schooling (detailed history of schooling, shifting of schooling if any, adjustment issues at
school, relationships with teachers and classmates, performance in academic and non-
academic activities, academic grades, any incident happened during schooling such as
bullying)
 Adolescence (age of puberty, information regarding puberty, reaction towards puberty,
information regarding sex)
 Sexual inclination(homosexuality/heterosexuality if reported)

Marital History:

Spouse:
Alive/dead: Age: Education:

Occupation: Cause of death:

Physical heath: ________________

Any psychiatric problem:

Personality:

Nature of relationship with client:

Relationship with spouse family

 If strained, why/cause

Children:

Total No: Son: Age:

Daughter: Age:

Physical health:

Any psychiatric problem:

Relationship with children:

If strained, why/cause:

Overall home atmosphere:

Occupational History: (If client is doing job)

Age at which client starts occupation: -------------------------

Name of Occupation------------------------

Relationship with co-workers: --------------------

Change in occupations if any: ---------------

Reason of occupation change: --------------

Any dispute with co-workers: -------------

Premorbid Personality (The premorbid personality is an indication of the client's

personality and character before the onset of mental illness)
 Social interest
 Social relationships
 Mood
 Moral and religious values
 Habits
 Reactions to stress
 Smoking/ Drug abuse

Note: Please note that all the above-mentioned points have been given to you for your
guidance. You have to write all sections of history in form of a paragraph in past tense.
History is very important for diagnosing the client accurately, and in management of their
problem, so please give detailed history, mention all predisposing and significant factors.
Assessment
It is divided into two parts.

Informal Assessment includes:

 Baseline chart
 Subjective ratings of presenting complaints
Formal Assessment includes:

 Mental Status Examination

 Diagnostic/Psychological Assessment
 Personality Assessment

Mental Status Examination:

Appearance:

Following points about the client’s appearance must be mentioned under this section:

 Sitting posture
 Facial Features:
 Hair color
 Texture
 Styling and grooming
 Height
 Weight
 Body Shape
 Cleanliness
 Neatness
 Clothing/Dressing
 Level of Eye Contact
 Eye Movement
 Degree of friendliness
 Apparent Age
 Mannerism

Speech (Form and Content)

 Volume of Speech
 Stammering/stuttering

Mood and Affect:

Thoughts:

 Stream of Thought
 ‫‪‬‬ ‫‪Thought Content‬‬

‫‪Delusions:‬‬

‫کیا آپ کو اس بات کا یقین ہے کہ کوئی دو لوگ آپ کے خالف بات کر رہے ہیں؟‬

‫کیا آپ کو ایسا محسوس ہوتا ہے کہ ٓا پ کے قریبی رشتے دار آپ کے خالف ہیں؟۔‬
‫کیا آپ کو ایسا لگتا ہے کہ آپ کا تعلق کسی عظیم ہستی سے ہے؟‬
‫‪Hallucinations:‬‬

‫کیا آپ کو ایسی آوازیں سنائی دیتی ہیں جو دوسروں کو دکھائی نہیں دیتی؟‬
‫کیا آپ کو ایسی شکلیں دکھائی دیتی ہیں جو دوسروں کو نظر نہیں آتیں؟۔‬

‫‪Orientation:‬‬

‫‪Orientation (Time):‬‬

‫آج کیا تاریخ ہے؟‬

‫یہ کونسا مہینہ ہے؟‬

‫‪Orientation (Place):‬‬

‫یہ کونسی جگہ ہے؟‬

‫یہ کونسا شہر ہے؟‬

‫‪Orientation (Person):‬‬

‫میرا نام کیا ہے؟‬

‫‪Memory:‬‬
‫‪Remote memory:‬‬
‫آپ کہاں پیدا ہوئے؟‬

‫‪Recent Past Memory:‬‬

‫آپ نے کل ٹی وی پر کونسا پروگرام دیکھا؟‬

‫‪Recent Memory:‬‬
 ‫ان الفاظ کو اسی ترتیب سے دہرائیں۔ کرسی۔ میز۔ الماری۔‬

General information/intelligence:
General knowledge questions
‫ کتنے ہوتے ہیں؟‬۲ ‫ جمع‬۵

Insight:

‫آپ کی بیماری کس نوعیت کی ہے؟‬

Summary of Informal and Formal Psychological Assessment

Diagnosis:

According to DSM-5, the client is diagnosed with

Disorder Code, Name of disorder, specifier

Prognosis:

Recovery (Satisfactory/Unsatisfactory)

Management and Treatment:

 Family Counselling

Case Formulation:

In case formulation section, you are supposed to add the reference of school of thoughts or
researches to endorse the reasons of manifestation of any disorder. Suppose if the reason is
unconscious conflicts, then you can support your case with the help of psycho-dynamic school of
thought. You are also required to find research studies that have been done in regard of that
school of thought and that are also linked somewhat to your client's identified problem.

Appendances:
This part would include the scanned copies of tests being used for the assessment of the client.
Mainly your report should encompass following sections, it has already been discussed in the
format, but few details are as follows:

1. Background Information/ History

For instance, marital status, no of children (if any), work, health status, family mental health
history, family and social relationships, drug and alcohol history, life difficulties, goals, and
coping skills and weaknesses.

2. Description of the Presenting Problem

In the next section of your case study, you will describe the problem or symptoms that the client
presented with. Describe any physical, emotional, or sensory symptoms reported by the client.
Thoughts, feelings, and perceptions related to the symptoms should also be noted. Any screening
or diagnostic assessments that are used should also be described in detail and all scores reported.

3. Your Diagnosis
Provide your diagnosis and give the appropriate DSM-5 code. Explain how you reached your
diagnosis, how the clients symptoms fit the diagnostic criteria for the disorder(s), or any possible
difficulties in reaching a diagnosis.

4. Intervention and Recommendations

The second section of your report will focus on the interventions that can be used to help the
client. You may summarize two or more possible treatment approaches. Identify all the possible
social, psychological and biological factors that can contribute to the problem of your client and
provide recommendations accordingly.

5. Case formulation:
In case formulation you have to link your case with the prevailing theories and researches. You
have to discuss which theory/school of thought supports this case, the causes that contributed in
client’s problems.

6. Appendixes
This part would include the scanned copies of tests being used for the assessment of the client.

Note:
I. Complete all the required parts of your report.
II. Though report would be written on only two cases but for presentation & viva voce,
do prepare yourself to talk about the other cases and your experiences during your
internship.
III. The internship report should be double space typed on A4 size with bold headings and sub
headings, with margins set at top, bottom and right 1 inch whereas left margin should be
1.5 inch.
IV. Internship Report should be uploaded on LMS as an assignment. Hard copy of this report is
not required.

V. Students will be provided reference letter by the university on request. They have to specify
the name and address of the organization and concerned person, along with their own complete
e-mail address and phone number. Students can send their request for internship letter at this
mailing address: psyi619@vu.edu.pk