Format of Internship Report for Clinical Psychology

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

 Take case studies 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, occupation, income, date
of admission.

Main reasons for referral:

Presenting complaints:
1.
2.
3.
4.
5.

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

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
 Early development
 Physical health/ Medical history
 Traumatic experiences
 Any psychological problem
 Schooling
 Developmental Milestone
 Adolescence
  Occupation
 Sexual inclination
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:

Premorbid Personality
 Social interest
 Social relationships
 Mood
 Moral and religious values
 Habits
 Reactions to stress
 Smoking/ Drug abuse
 Psychiatric traits/problem

Previous and Present Psychological Problem:

Please give details of Previous and present psychological problem of your client.

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.

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:

Thoughts:

 Stream of Thought
 Thought Content

Delusions:
 ‫کیا آپ کو اس بات کا یقین ہے کہ کوئی دو لوگ آپ کے خلف بات کر رہے ہیں؟‬
‫کیا آپ کو ایسا محسوس ہوتا ہے کہ ا پ کے قریبی رشتے دار آپ کے خلف 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
۵ ‫ کتنے ہوتے ہیں؟‬۲ ‫جمع‬

Insight:

‫آپ کی بیماری کس نوعیت کی ہے؟‬

Summary of Informal and Formal Psychological Assessment:

Informal Assessment includes:

 Clinical Interview
 Mental Status Examination

Formal Assessment includes:

 Diagnostic Assessment Test

 Personality Assessment Test

Any other important information:

Diagnosis:

If you are following DSM4-TR, please give diagnosis as per following:

Axis I: Clinical Disorders; Other Conditions That May Be a Focus of Clinical Attention
Axis II: Personality Disorders And Intellectual Disabilities
Axis III: Medical Or Neurological Conditions That May Influence A Psychiatric
Axis IV: Environmental and psychosocial stressors/problems
Axis V: Global Assessment of Functioning (GAF)

If you are following DSM-5, please give one provisional diagnosis.

Prognosis:
Recovery (Satisfactory/Unsatisfactory)

Management and Treatment:

 Pharmacological
 Psychological/psychotherapy
 Family Counselling
Follow up Plans

Any Suggestions/Recommendations

Case Formulation:

Appendances:
This part would include the scanned copies of tests being used for the assessment of the client.
Instructions:

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-IV/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, consisting of at least 10,000 to 15,000 words.
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