Regardless of its purpose, no psychological evaluation is complete without historical

Clinical Intake Report Instructions


Regardless of its purpose, no psychological evaluation is complete without historical or background information about an examinee.  Historical information about the examinee is absolutely necessary to an evaluator when he/she interprets results from psychological tests because similar patterns of test scores could suggest different things about examinees with different life experiences.  Background information usually is gathered in an interview, but a biographical information sheet completed by the examinee also can be very useful.  Typically, information regarding the examinee’s family and social/relationship history, work experience, educational history, and medical and legal problems is gathered.  Additionally, the evaluator is interested in an examinee’s self-perceptions, significant life experiences, goals/aspirations etc.

For the current assignment, imagine that you are a therapist at a Christian Counseling Center, and you are assigned a new client from whom you must collect historical information.

Step 1: Conduct a Clinical Interview.

• A template for a comprehensive Clinical Interview is provided in the Assignment Instructions folder in BlackBoard.
• Use the Clinical Interview template to conduct clinical interview on yourself or on a willing and generous volunteer who is at least 18 years old!
• You DO NOT have to complete the entire interview.
ο Complete the following 4 required sections of the Clinical Interview:
1. Demographic Information
2. Initial/General Impressions
3. Reason for Coming/Presenting Concerns
4. Initial Treatment Recommendations*****
ο Select 4 of the following optional sections of the Clinical Interview to complete:
1. Current and Recent Situation
2. Previous Assessments/Counseling Experiences
3. Birth and Developmental History
4. Family of Origin/Family Constellation
5. Early Recollections
6. Marital and Family Data
7. Medical History
8. Education and Training
9. Work Background/History
10. Recreation, Interests and Pleasures
11. Social Support, Communication Network, and Social Interests
12. Self-Description
13. Choices and Turning Points in Life
14. Personal Goals and View of the Future
• Remember that any information you gather about the examinee must be kept COMPLETELY CONFIDENTIAL!  In conducting this clinical interview, you are bound by the same ethical and professional standards of all mental health care providers (e.g., psychologists, licensed counselors, licensed clinical social workers etc.)

Step 2: Write a Clinical Intake Report.

• Based on the information that you gather in the clinical interview, write a Clinical Intake Report.
• Your report should include summaries of the 4 required sections of the clinical interview described above as well as summaries of the 4 optional sections that you selected.
• *****IMPORTANT NOTE: In the Initial Treatment Recommendations section of your clinical intake report, you are required to identify and describe at least ONE Biblically-based treatment recommendation given your examinee’s reason for coming/presenting concern(s).  Additonally, you must provide at least ONE scriptural citation that supports the use of the Biblically-based intervention that you described.
• Include an APA-formatted Title Page to begin your report.
• Your completed report should be typed, double-spaced, and 3–5 pages in length (not including the title page).
• Please DO NOT refer to the examinee by his/her full name in your report.  Instead, refer to the examinee by his/her title and first letter of last name.  (For example, refer to Dr. William Jones as “Dr. J,” or refer to unmarried Samantha Murphy as “Ms. M.”)
• Write in the third person (e.g., Dr. J. is a a 42-year-old, married, white male…, “ “His greatest strengths are….”
• A template for a Clinical Intake Report is provide in the Assignment Instructions folder in BlackBoard.  Be sure to either use or refer to this template when putting together your final report.
• A sample completed Clinical Intake Report also is provided in the Assignment Instructions folder in BlackBoard.
ο This sample document is a comprehensive report and includes a summary of all of the typical, major elements of a full clinical interview.
ο Your report will NOT be as long as the sample!  Your report will include only 8 sections—the 4 required sections and 4 optional sections that you chose.
ο Refer to this sample report only as a guide for how to approach your final report.


Be sure to carefully review the grading rubric posted in the Assignment Instructions folder so that you know exactly what is expected of you when completing this assignment.

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