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    Case History Format of Child

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    shivani singh
    The document contains a psychological assessment report of a client. It includes details of the client's personal history, developmental history, behavioral characteristics, reason for referral, areas to be investigated, tests administered, test findings, impression, and recommendations from the assessing clinical psychologist.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Case History Format of Child

    Uploaded by

    shivani singh
    5 views8 pages
    The document contains a psychological assessment report of a client. It includes details of the client's personal history, developmental history, behavioral characteristics, reason for referral, areas to be investigated, tests administered, test findings, impression, and recommendations from the assessing clinical psychologist.

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    case history format of child

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    The document contains a psychological assessment report of a client. It includes details of the client's personal history, developmental history, behavioral characteristics, reason for referral, areas to be investigated, tests administered, test findings, impression, and recommendations from the assessing clinical psychologist.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    5 views8 pages

    Case History Format of Child

    Uploaded by

    shivani singh
    The document contains a psychological assessment report of a client. It includes details of the client's personal history, developmental history, behavioral characteristics, reason for referral, areas to be investigated, tests administered, test findings, impression, and recommendations from the assessing clinical psychologist.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 8

    Psychological Assessment Report

    Socio-demographic Data

    Name:

    Age:

    Date of Birth:

    Education:

    Handedness:

    Occupation:

    Marital status:

    Religion:

    Languages: Mother tongue:

    Family Type:

    Present Address:

    Pin:

    State:

    Contact No.

    Source of referral:

    Previous consultation/hospitalization (Yes/No):

    Informant:

    Detail of informant (other than client):

    Relationship with Client:

    Reliability and Adequacy:

    Reason for consultation and Expectation:

    Information:
    Chief complaints:

    As per patient:

    As per informant:

    (i) Total duration of illness:

    (ii) Course of illness:

    (iii) Mode of Onset:

    (iv) No. of hospitalization:

    Precipitating Factor, (if any):

    BACKGROUND INFORMATION

    Client came to DBH on 15-11-2022 with presenting chief complaints of


    Personal History

    1. Birth history:

    (a) Prenatal history:

    (b) Peri-natal history:

    • Birthplace:

    • Term:

    • Delivery type:

    • Abnormal presentation:

    • Birth weight:

    • Birth cry:

    • Respiratory distress:

    • Multiple pregnancies:

    • Congenital anomalies:

    • Infections:

    • Feeding problems:

    • Convulsions:

    (c) Post-natal History:

    • Infection:

    • Fever:

    • Jaundice:

    • Convulsion:
    • Injury:

    • Failure to thrive:

    • Loss of Consciousness:

    (d) Immunization History:

    • Polio:

    • Diphtheria:

    • Tetanus:

    • MMR:

    • Boosters:

    • Others:

    • Post Immunization reactions:

    2. Developmental History

    (a) Motor:

    • Head control:

    • Sitting:

    • Walking:

    • Coordination of movements:

    • Irregular movements:

    (b) Speech and Language:

    • Babbling:

    • First word:

    • Two-word phrases:

    • Sentences:

    • Defective articulation, stuttering, stammering, echolalia etc.:


    (c) Adaptive:

    • Avoiding Common dangers:

    • Writing few alphabets:

    (d) Personal and Social:

    • Smiles at others:

    • Responds to name:

    • Temper Tantrums:

    • Food at Self:

    • Bladder and bowel control:

    (e) School History:

    • Normal school/ special school:

    • Age of entry:

    • Academic performance:

    • Extracurricular Activities:

    • Attendance:

    • Classroom behavior:

    • Behavioral problems:

    • Relationship with peers and teachers:

    (f) Play:

    • Preferences:

    • Special likes and dislikes:


    (g) Puberty Development:

    3. Behavioral characteristics:

    • Activity level:

    • Approach/ Withdrawal:

    • Sensitivity threshold:

    • Intensity or emotional response:

    • Distractibility:

    • Quality of mood:

    • Attention Span:

    REASON FOR REFFERAL

    AREAS TO BE INVESTIGATED

    TEST ADMINISTERED

    RATIONALE OF THE TEST


    Behavioral Observation

    (A) General Appearance:

    (B) Attitude towards test:

    (C) Attitude towards examiner:

    (D) Total sessions taken for testing:

    (E) Test Situation:

    TEST FINDINGS

    IMPRESSION

    RECOMMENDATION
    Assessed By:

    Shivani Singh

    M.Phil. Clinical Psychology

    Clinical Psychologist

    CRR No: 234142

    Professional Warning: This report is to be used in conjunction with professional judgment. The statements it contains
    should be viewed as hypotheses to be validated against other sources of data such as interviews, behavioural observation,
    and biographical data. All information in the report is confidential and should be treated responsibly.

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