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Detailed Case Analysis Form

The document is a comprehensive Psychological Case History Taking Form designed to gather detailed information about a client's background, presenting complaints, medical and developmental history, substance use, mental status, emotionality, academic performance, personality adjustment, relationships, and specific focus areas for assessment. It includes sections for the interviewer to document observations and responses, as well as challenges faced by the client and potential coping strategies. This structured format aims to facilitate a thorough understanding of the client's psychological state and needs.

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ankitatab97
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20 views6 pages

Detailed Case Analysis Form

The document is a comprehensive Psychological Case History Taking Form designed to gather detailed information about a client's background, presenting complaints, medical and developmental history, substance use, mental status, emotionality, academic performance, personality adjustment, relationships, and specific focus areas for assessment. It includes sections for the interviewer to document observations and responses, as well as challenges faced by the client and potential coping strategies. This structured format aims to facilitate a thorough understanding of the client's psychological state and needs.

Uploaded by

ankitatab97
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Psychological Case History Taking Form

1. General Information
Field Response
Name / Code of Client
Age
Gender
Date of Birth
Marital Status
Education Level
Occupation
Socio-economic status
Address
Contact Information
Date of Interview
Interviewer’s Name

2. Presenting Complaints
Complaint Duration Description

3. Medical History
Illness Year Treatment/ Current
Diagnosed Medications Status
If any

4. Developmental History
Stage Details
Prenatal & Birth type - C-section [ ] Natural [ ]
Birth Mention any complications during birth or before.
Infancy & Smiling, cooing, and babbling - Yes [ ] N0 [ ]
Early Rolling over - Yes [ ] N0 [ ]
Childhood Sitting alone without support - Yes [ ] N0 [ ]
(0-1) Crawling - Yes [ ] N0 [ ]
Reaching for object - Yes [ ] N0 [ ]
Todlerhood - Walking, climbing, and running - Yes [ ] N0 [ ]
(1-3) Following simple commands - Yes [ ] N0 [ ]
Pointing to body parts -Yes [ ] N0 [ ]
Playing peek-a-boo - Yes [ ] N0 [ ]
Using utensils and feeding themselves - Yes [ ]
N0 [ ]
Preschool Dressing and undressing with little help - Yes [ ]
(3-5) N0 [ ]
Hopping, jumping, and running with ease - Yes [
] N0 [ ]
Climbing steps with alternating feet - Yes [ ] N0 [
]
Singing songs - Yes [ ] N0 [ ]
Schooling Reading and writing - Yes [ ] N0 [ ]
age (5-12) Understanding and using numbers - Yes [ ] N0
[ ]
Developing social skills and friendships - Yes [ ]
N0 [ ]
Participating in sports or other extracurricular
activities - Yes [ ] N0 [ ]

5. Substance Use History


Substance Age of Frequency Last Use Dependenc
Onset e
Symptoms
If any

6. Mental Status Examination (MSE)


Parameter Observation
Appearance & Behavior Eg. Well dressed, shabby, polite etc.
Speech Eg. Firm, Low, loud, soft etc.
Mood & Affect Eg. Happy, energetic, sad, disturbed
etc.
Thought Process & Content Eg. Clear, precise, Confused,
dioriented
Perception Eg. Negativr/positive
Orientation Eg. Awareness of place, time and
who they are?
Memory Eg. Able to remember details about
anything you ask.
Insight & Judgment Eg. He/she is able to refelct on their
thoughts and explain if they in the
right direction for themselves.

7. Emotionality and agression

Emotions Manner of Coping


expression

Provide details on how their emotional expression is in general. Eg.


He/She cries when angry and copes better by talking to people around
her.

8. Academic and non-academic performance

Strength Weak Subject Strength area Weak area


Subject

Eg. Math - Finds English - Creativity - S/he S/he struggles


it easy to work Speaking skills can easily turn with social
with algebra are moderate. waste materials interaction and
sums and solves S/he is able to into use-able seeks attention
problems speak less products that from adults for
quicker than difficult words are quite his/her concern
peers. for grade level creative. rather than
compared to interacting with
peers. peers his/her
age.

9. Personality adjustment

Situation Adjustment

Eg. A’s mother yelled at him at Eg. A responded by aggressively


night to leave playing on his strutting her down saying “ You
phone and going back to sleep. need to let me enjoy my holidays
and stop bothering me.”

Situation can be of any nature either said by the client or your personal
observation.

10. Relationships with others:

Relation Interaction frequency Social skills


Person in relation eg. Eg. Once a week, daily Communication:
Friend, sister brother etc. Effectively conveying
etc. messages, both
verbally and non-
verbally.

Empathy:
Understanding and
sharing the feelings of
others.

Respect: Recognizing
and valuing the rights
and opinions of
others.

Active Listening:
Paying attention and
responding
thoughtfully to what
others say.

Problem-solving:
Finding constructive
solutions to conflicts
and challenges.

Emotional
Regulation:
Managing one's own
emotions and
understanding others'.

Social Awareness:
Understanding social
cues and norms in
different situations.

Cooperation:
Working effectively
with others to achieve
common goals.

Conflict Resolution:
Addressing
disagreements in a
constructive way

11. Specific focus areas - depending on the test that you are
doing anxiety/depression or stress.

Test used Results Use background


information to
analyse causes for
current situation.

Stress test High stress A comes from a low


income background.
Studies suggest that
low income correlates
with major financial
constraints in daily life
as observed in A’s
case where he is
always struggling to
meet academic
requirements and
helping out his mother
at home for house
chores. This causes
significant stress to
the child as he is
found to be
financially,
environmentally, and
emotionally. Tackling
with multiple concerns
day in and out.

12. Challenges faced by the subject. (Write 2)

Challenging Emotional Coping Possible


situation Response strategy solutions that
can be
suggested by
interviewer

I am not able to Constant Talking to a Mindfulness,


work with burnout, crying friend and going breathing
concentration and anger fits out on a bike techniques and
ride. therapy
sessions with
professional
depending on
access.

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