Make up a letterhead from your fake private practice office. Number your pages.

** Follow the format presented here. Include & label each section. Remove my notes and highlights in your draft. Keep in mind that you are going to have to discuss therapy and ethnicity factors in the second part of your paper. Set yourself up for success by including the factors you will have to address in these sections within the description of your subject. Be sure to differentiate what your client reported by using quotes from your subject or write tentative sentences like “The subject reported that …” 



Patient:  Jane Doe                                        Examiner: YOUR NAME

DOB:     01/01/01                                           Dates administered: 1/1/2020          

This report may contain sensitive psychological information and is intended as a diagnostic or treatment aid for mental health, health, legal, or academic professionals.  Specific test scores included within it should not be released to the patient under any circumstances, except by a qualified mental health professional.  Patient access to such information may be deemed clinically inappropriate, as covered by the Patient’s Access to Health Records Act (California Health and Safety Code, Sections 25250 through 25258) and Ethics Code Standard 2.02 of the American Psychological Association’s Ethical Principles and Code of Conduct.

Reason for Referral

            Jane Doe is a 32-year-old Hispanic female who was referred by . . . Mrs. Doe reports her presenting problems to be . . .  These problems have been present intermittently/chronically since . . . In this section, you are introducing the reader to your subject.  Qualitatively describe the symptoms they are concerned about from the subject’s point of view (not the referrer).  Include a quote of several sentences from the subject in the words you would expect them to use (subjects don’t use formal psychological terms and don’t list criteria specifically). Keep this section brief.  You can add some information from a secondary source (referring doctor or relative) if it makes sense. This is only the introduction (reader should start to get hypothesis from subject complaints offered here).

Background Information

            Background information was gathered from verbal reports provided by Mrs. Jane Doe, verbal reports provided by her mother (current caretaker of the children), and Ventura County Human Services records (records may also be from school, previous psychological testing, police report, etc.). Do not add any other info here other than who and what records provided info.


            Jane Doe lives in a rented house with . . .  Complete this section including who she lives with, ages, and occupations.


Use this format replacing appropriate information.  The subject’s birth history revealed a normal, full-term pregnancy. Mrs. XX was XX years old when XX was born, and this was her second pregnancy. Mrs. XX denied prenatal exposure to nicotine, alcohol, medications, or street drugs. XX was born by planned c-section due to breech position after no hours of labor. There was no indication of prenatal distress. XX was nursed for three months, then formula fed because her mother returned to work. There were no reported problems with eating, sleeping, or colic as an infant.

In regard to infant and toddler temperament, XX was described as having  “difficult” temperament, “average” sociability, “above average” insistence, and had an “above average” activity level.  Developmental motor and speech milestones were reportedly reached within normal limits. She was toilet trained at 14 months with no difficulty.


Start with a one- or two-sentence quote about how they described their childhood overall. Add information about where they grew up, with whom, quotes about their relationship with each family member, and any other relevant issues (history of abuse, religion, socioeconomic status, etc.).


How much school completed by subject? Private or public schooling? Their grades (gpa) and if they applied little, average, or a lot of effort to obtain their grades. Any other academic support – GATE, IEP, tutoring, etc.


How many close friends does the subject have? What do they like to do for fun? Are tehy satisfied with their social life? Are they currently in an intimate relationship? What is the quality of that relationship? Have they had prior committed relationships?




Medical history showed no significant acute or chronic illness, brain injuries, poisoning, or broken bones. Change this info as applicable. Model this section after the developmental section with appropriate info like current and previous medical conditions and treatment, meds, surgeries? Substance use? Be specific about types and doses.


Detail previous treatment or evaluation, psychiatric hospitalizations, & family psychiatric history of first-degree relatives.

Evaluation Tools and Instruments (you can keep this as is or add to it if you’d like)

Clinical Interview

Physical Complaints Checklist

Review of Records

Self-Rating Symptom Checklist

Mental Status Exam/Behavioral Observations

You can copy and paste this as is, but change information as applies to your case. (It’s not plagiarism if your professor provides it for you and asks you to cut and paste it.)

            Mrs. Doe is a Hispanic female of average height and weight.  She was clean, well groomed, and casually dressed for each testing session.  Throughout testing she was oriented to time, person, place, and situation and was cooperative with euthymic mood and congruent affect.  She spoke with an average tone and pace without abnormal speech or neologisms.  She denied current or past visual or auditory hallucinations or homicidal or suicidal ideation.  There was no evidence of psychotic thought process such as cognitive slowing, poor thought organization, poverty of content of thought, delusions, tangentiality, or visual or auditory hallucinations.  She appeared to be of average intelligence without significant memory impairment.

Overall, the subject displayed fair judgment and insight during testing.  She appeared to be honest, but guarded and overly concise in her disclosures, demonstrating little affect despite topic of discussion.  She voluntarily signed consents for the examiner and made the necessary arrangements in her work schedule to complete several sessions of testing.  She was punctual for each appointment. 


Evaluation Results


This section is optional if your subject is a child only. It can be a school observation and parent-child play observation. Delete the section if you don’t have a child subject.


Make your subject a person of color and unique ethnicity. Address SEVERAL relevant cultural and ethnicity factors, including language and level of acculturation (years since immigration, family practices, language, values, holidays celebrated, tv watched, etc.). YOU WILL HAVE TO DO RESEARCH ON ETHNICITY AS IT RELATES TO PSYCHOLOGICAL PRESENTATION AND TREATMENT TO COMPLETE THIS SECTION. I EXPECT AT LEAST 3 CITATIONS (I included one in the module to get you started. It is optional if you want to use the article.)

Make sure you state that you would seek consultation as necessary if you are of different ethnicity than your subject (or refer to a psychologist of the same background), consider what is typical in the client’s cultural group before giving a diagnosis, and consider the person’s values and preferences when giving referrals for community resources.

Be sensitive here. Don’t say outrageous generalizations like, “because the client is Latina, she…” Instead, make observations with evidence (e.g., “the client revealed that in her family’s Mexican-American culture, men are often expected to demonstrate machismo which may have affected her relationship with her father…). Use words like “this issue MAY be a consideration” rather than making statements that suggest ethnicity issues necessarily apply to your client simply because they are of that ethnicity. This section is critical to your overall grade. Do the research and speak professionally. Beware of falling into stereotypes.


Lead this section with your diagnoses and the criteria met that led you to it.  Don’t use bullet points. Make sure you list sufficient criteria for each diagnosis and include comprehensive information (e.g., mild, moderate, or severe for substance use disorder). Create the list in paragraph form. You can also elaborate on relevant symptoms that may not be specific DSM-5 criteria but are still relevant to the presentation.  Use qualitative descriptions and examples to illustrate your diagnostic conclusions.

The subject meets clinical criteria for ….. Specific criteria met includes

Summary & Conclusions

Start with diagnosis and criteria met in paragraph form. Then concisely summarize relevant information from each section of your report. You may either state that the section was insignificant (e.g., developmental history was insignificant) or quickly list what was significant in that section (e.g., developmental history revealed that the subject was born four weeks prematurely and was treated in the NICU for the first two weeks of her life).  This section should only be about 3-6 paragraphs.  Reading this section should provide a good summary of the case if the reader were to go to it first (they would read the body of the report for detail).  Only summarize previous sections – do not include any new information here!!

Recommendations & Referrals

Take time with this section. Bullet list other professionals or resources that may be helpful to the subject. Also include what treatment you are recommending from that referral (within your expertise as a psychologist). Don’t recommend specific meds. Consider what team treatment is important for the treatment of the subject’s diagnoses.

  • Referral to psychiatrist for psychopharmacological evaluation to treat impairing symptoms of….
  • Group therapy for …

Treatment issues

Detail factors that may affect the subject-examiner alliance and success in completing this intake. How might these factors impact treatment (trust, motivation, history of relationships, ethnicity, SES, gender, age, thought process, history of follow-through & cooperation, psychological insight, any factors that would interfere with the subject’s ability to make it and pay for a weekly session, social support, & ethical and legal concerns.  Be creative & include original ideas.

Treatment plan (one treatment plan for your client – not one per diagnosis)


List up to three bullet-listed goals as a measurable decrease of the primary distressing/impairing symptoms (e.g., decrease depressed mood from 80% of the time to 20% of the time or decrease handwashing from 10 minutes to 2 minutes per episode). Immediate goals must address crises like suicidality and substance abuse detox as applicable (i.e., what is quantity of behavior now vs. how it will look when treatment is successful & ready to terminate)

INTERVENTIONS (these are interventions you will do as a psychologist with the subject as if you were the treatment provider, not what your referral resources will do – not the place to talk about medications, for example).

List 3-10  bullet-listed psychotherapy & CBT interventions to eliminate crisis factors such as offering psychoeducation, & techniques to build the therapeutic alliance. Do not list interventions from the professionals on your recommendation list (like medication, social work, PT, OT etc.)


List up to 3 bullet-listed measurable goals that will make up the bulk of therapy. These are usually specific symptoms related to DSM-5 criteria. Tie the goals to specific symptoms from the diagnoses.


Get creative. You can repeat interventions as necessary. Don’t just say “administer CBT.” Bullet-list 3-10 specific psychotherapy and CBT techniques as they apply to your goals of symptom reduction. Do not list interventions from the professionals on your recommendation list (like medication, social work, PT, OT etc.)


Bullet-list up to 3 measurable goals. Long-term goals typically deal with long-term personality & situational issues and prep for termination. State how you would taper treatment to maintain gains prior to termination.


Bullet-list 3-10 specific PSYCHOTHERAPY & CBT techniques as they apply to your goals of symptom reduction.

___________________________                              ____________________________   

Your signature & Title                                                Date