This document outlines the headings that should be included in a written report. It will cover: 1) Referral information including identifying details and reason for referral. 2) History of present condition rather than assuming something is wrong. 3) Medical history including hospitalizations, treatments, medications, allergies and healthcare providers. 4) Family and social history using information from Intake 3. 5) Mental status exam following the outlined structure exactly. 6) Diagnostic impression covering all 5 diagnostic axes. 7) Summary and recommendations summarizing the assessment without new information and including treatment suggestions.

1. Written Report Outline
You will be asked to complete one written report for the term, by beginning with the first
heading and adding information for each subsequent heading in the weeks that follow. I
will edit your weekly submission and return it to you for corrections. The next week’s
heading should contain last week’s corrections, plus the new info for this week.
Each written report will cover the following information, under the same headings listed,
and in the same order. All of this information can be gathered using the file Intake3.
Referral (a statement containing the person’s identifying information such as title, name,
age, marital status, race, sex and reason for the referral. This will be the question you
must answer in the end)
History of Present Condition (medical model uses History of Presenting Illness or
History of Present Complaint. Both automatically assume something is wrong. That’s why
I changed mine to read as you see it. It’s entirely possible there is nothing wrong with the
person, so why begin with that assumption?)
Medical History (psychiatric hospitalizations, surgeries, treatments, other diseases or
disorders [not psychiatric], current medications, drug allergies, current physician,
psychiatrist, psychologist, counselor, etc. and last time seen.)
Family and Social History (used to be Social and Family History and in separate
headings. Look at the info sought in Intake 3 for this category)
Mental Status Exam (I’ve given you a very good outline of one. Follow it exactly and
cover every aspect of it.)
Tests Administered (will not be used for this class. Most Master’s level practitioners are
not able to administer psychological tests due to licensing limitations and training)
Test Results (same as above)
Diagnostic Impression (Ensure you cover all 5 Axes)
Summary and Recommendations (No new information should appear here. If it has not
been mentioned above, do not add it here. Remember, this is a summary of what’s been
done. Recommendations are those things you consider might be helpful for the patient)
Signature Element (this is not a heading, but you must identify yourself at the end of
the report)