Adult Case Report Format 1

General Guidelines for Write up of Adult Case Report

General requirements: APA 7th edition should be followed including

● Case report should be written in Times New Romans

● Insert page number at the right top of the page
● Write case report number at the left top of the page by using Header
● Indent each paragraph with line spacing 1.5 with left alignment
● Heading should be followed with the help of APA format.
● 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 according to the APA
● Give appropriate reference of each technique and assessment tool.
● Give reference in text and in Reference List according to APA 7th Edition specification
Sequence of Initial Pages

o Title page (Appendix – A)

o Table of Content
o Declaration (Appendix – B)
o Case report completion certificate (Appendix – C)
o Acknowledgment
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o Summary of the Cases (Appendix – D): Table form (client’s initials, age, gender, presenting complains, number of sessions,
assessment, diagnosis, management, outcome (in percentage)).
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Adult Case Report Format

● Summary of the Case. (complete brief description of the case, presenting complaints, assessment results with diagnosis and
management plan with number of session and outcome report in one paragraph)
● Identifying Data.(initials of the client’s name, age, gender, in-patient or out-patient, marital status, education, no. of sessions,
date seen and last date seen)
● Source and Reason for referral. (e.g. Source of the referral: informants, client, psychologist)
● Presenting Complaints.(complaints in the clients verbatim along with their complaints duration by the psychologist/informant
and by the client)
● Initial Observation. (appearance, posture, speech, eye contact, behavior on initial contact, client’s own perception of the
referral, and any other important significant behavior your observed in the session)
Developmental History of the Problem
● Source of information.
● Chronological course of the problem
● What is the problem, when it started, how it maintained and what is the current level of client’s problem. Highlight the events
that made the client vulnerable towards the problem.
● The current status of the client’s problem
Background information
● Personal history (client’s current routine, daily activities, hobbies, likes and dislikes, free time activities, history of accident,
head injury, physical injuries, religious inclination)
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● Premorbid History (the client’s personal, social and occupational functioning before the illness)
● Family history (family system, number of family members, any significant information, Socio-economic Status, family
environment, interaction with family members, genogram, parental education and occupation)
● Sexual history (pubertal changes, reaction toward puberty, sexual relationships, reaction toward those sexual activities)
● Marital history (arrange or love marriage. spouse age, education, occupation, duration of marriage, Relationship with spouse,
any conflict reported etc)
● Educational history (schooling started at what age, school performance, interaction with teachers and class fellows).
● Occupational history (Detail of jobs, client view about his job, satisfaction, relationship with colleagues etc)
● History of family psychiatry / medical illness
● Provisional formulation. Overall conclusion based on the history, including brief summary of risk and protective and
maintaining factors of the problem.
● Assessment. List of the assessment modalities, write rationale of each assessment modality and procedure by relating with the
clients problem.
o List of Assessment Modalities includes Behavioral observation, clinical interview, Mental Status Examination, subjective ratings
of the problem, baseline chart, neuropsychological assessment, projective tests (TAT, ORT, etc), Self Report Measures.
o Add qualitative and quantitative interpretation of the test scored used for assessment
o Add overall general conclusion of assessment
● Case formulation (summarize all the contributing predisposing, precipitating, maintaining, and protective factors that lead to
the current problem, strength and weakness of the client). 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
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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. poor financial conditions lack of health facilities and family support and client’s
personal motivation), protective factors (the factors that can help the client to cope with the problem e.g. client’s own easy
temperament, family bonding)
● Pictorial Description of case formulation (summarize the client’s problem in pictorial manner) (Appendix E)
● Suspected Problem (support your diagnosis with the symptoms and course of problem according to DSM-5)
● Intervention plan (on the basis of assessment results enlist the goals for the management of the clients problem)
● Intervention strategies. Write the rational of each technique by relating with the problem of the client. How it was used with
the client, write the process and how client felt and responded.
o Termination of the Therapy (write how the session were terminated with the client)
● Outcome. (Report the comparison with the help of pre and post subjective rating of the client’s problem with the help of table
& histogram)
● Limitations.(what are the limitations you have faced in order to deal with the client and achieving short and long term
management goals)
● Recommendations (further suggestions that might help the client in future in dealing with the client, follow up)
● Session reports. (session by session report with goals, activities, client’s behavior and outcome)
● List of references (as per APA 6th 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)
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Portfolio
Content of Portfolio

1. Weekly Log Book (Appendix – F)

2. Portfolio Cases

3. Group Activities

4. Workshops Attended / Conducted

5. Presentations Attended / Conducted

6. Case Conferences Attended / Given

7. Creative Section

8. Placement Observation with suggestions

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Department of Clinical Psychology

School of Professional Psychology
University of Management and Technology
We train Professionals
Certificate of Approval of Case Reports
(Adult Placement)

Name of Participant/Candidate__________________________ Participant ID_____________

APA Format (7th Edition)

▪ Title Page (See Appendix for Guidelines) Yes No

▪ Case Report Completion Certificate Yes No

▪ Declaration Yes No

▪ Table of Contents Yes No

▪ Font size Yes No

▪ Spacing Yes No

▪ Margins Yes No

▪ Page numbers Yes No

▪ Alignment Yes No
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▪ Reference citation Yes No

▪ Tables Yes No

▪ Grammar Check (by using software e.g. Ginger) Yes No

▪ Quality of Expression Yes No

Case Report

1. Summary of the Case Yes No

2. Identifying Data Yes No
2.1 Initials of name Yes No
2.2 Age Yes No
2.3 Gender Yes No
2.4 Marital status Yes No
2.5 Institute Block Yes No
2.6 Date Seen Yes No
2.7 Last Date Seen Yes No
2.8 No of sessions Yes No
3. Reason of referral Yes No
4. Presenting Complaints Yes No
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5. Initial Observation Yes No

6. Developmental history of problem Yes No
7. Background information Yes No
7.1 Personal history Yes No
7.2 Premorbid history Yes No
7.3 Family history Yes No
7.4 Marital history Yes No
7.5 Educational history Yes No
7.6 Occupational history Yes No
7.7 Medication history Yes No
7.8 History of medical/psychiatric illness Yes No
8. Provisional formulation Yes No
9. Assessment Yes No
10. Case formulation Yes No
11. Summary of case formulation (table, pictorial) Yes No
12. Diagnosis Yes No
13. Intervention Plan Yes No
14. Implementation of strategies Yes No
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15. Outcome Yes No

16. Pre and post table & histogram Yes No
17. Limitations & Recommendations Yes No
18. Session reports Yes No
19. Reference list Yes No
20. Appendices Yes No

❖ This document is approved/not approved to be presented to the ________________________ Institute of Clinical Psychology.

Signature of the Participant/ Candidate ____________________________________

Date __________________ _

Signature of the Supervisor ____________________________________

Date __________________ _