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Case History
1. Demographic Profile
A. Name:
B. Age:
C. Gender:
D. Educational qualification:
E. Occupation:
F. Income:
G. Marital status:
2.Basic Background of the Clients (Q&A Format )
A. Whether client stays with parents:
B. Whether client stays with spouse!
C. Whether have any siblings, if so, how many;
D. What is the position of the client in the family: Eldest, middle or
youngest or only child?
E. Anyone in the family having conflicts:
F. Anyone in the family is suffering/has suffered from any physical
disorders
3. Defining Problems (Q&A Format )
• A. Presenting problem: (This should be recorded as the client
narrates)
• B. Date of onset of the problem:
• C. Precipitating factor if any:
• D. Duration of problem:
• E. Any counselling taken:
4. How intense is the problem and how does
it affect the client? (Q&A Format )
A. Has to take leave from workplace / school/college
B. Cannot carry on even the routine work
C. Does not want to do anything
5. Interview with family members/spouse/the
concerned person (Q&A Format)
• Their viewpoint in regard to all of the above
• The interview with family members should cover all aspects that are
covered in the interview with the client.
Client’s relationship with family members:
• If unmarried: With Mother/ Father /Brothers /Sisters
• Any other relative staying with client
A. With friends: How many friends does the client have?
B. How does the client relate to them?
C. With neighbours
D. With school and classmates
E. With the teachers in school
F. With other authority figures
G. With playmates
H. In the games field
6. Educational history: (Q&A Format)
In School/College:
• How is the client in studies and academic performance?
• Does the client come up to the expectations of parents and teachers?
• How has the performance been over the years?
• Do they find that there is sudden deterioration in studies and academic performance?
• Have they received any complaints from the school authorities regarding the client’s
performance?
• Since when have they noted that the client is not the same in regard to academics as he
or she used to be?
• Had they done anything about it so far? If so what?
• After their efforts had there been any improvement?
• When did they decide to consult a counsellor?
7. Work history: (Q&A Format)
• What occupation is the client involved?
• How regular is the client for work?
• Has the client been complaining about workplace? If so, what?
• Generally, how has the client been fairing in work?
• What is their perception about client’s relationship in the workplace?
With Boss: With colleagues: With subordinates:
8. If Married: (Q&A Format)
• Relationship with spouse in terms of
• Day to day dealings
• Sex life
• Work relationship (if spouse is working)
• Relationship with children
• Relationship with opposite sex persons
• Decision making (who takes the decision - spouse or self)
• Sharing of work at home with the spouse
• Relationship with spouse’s relatives
• Relationship with spouse’s friends Record every issue in detail verbatim, that is
as is being narrated by the client’s family members.
9. Observation About Client (write in
Paragraph format)
• Client’s presentation
• Client’s personal appearance
• Client’s social interaction with office staff and others in the waiting area
• Whether the client is accompanied by someone (This helps to determine if the
client has social support)
• Note the personal grooming
• Note things as obvious as hygiene
• Note things such as whether the employee is dressed appropriately according to
the season
• Note if employee is talking to himself or herself in the waiting area
• Note if the employee is pacing up and down outside the office door
• Record all observations
10. Establish rapport (write in Paragraph
format)
• By introducing yourself and ask the client’s introduction
• Speak directly to the client during the introduction.
• Pay attention whether the client is maintaining the eye contact.
• Make the client comfortable by offering him a glass of water or talk
about the weather outside.
MSE
(Mental Status of Examination)
1) Appearance. The psychologist notes the person’s age, sex, and overall appearance. These features
are significant because poor personal hygiene or grooming may reflect a loss of interest in self care or
physical inability to bathe or dress oneself.
2) Movement and Behavior. The psychologist observes the person’s gait (manner of walking,
posture, coordination, eye contact, facial expressions, and similar behaviors. Problems with walking
or coordination may reflect a disorder of the central nervous’ system.
3) Affect. Affect refers to a person’s outwardly observable emotional reactions. It may include either
a lack of emotional response to an event or an overreaction.
4) Mood. Mood refers to the underlying emotional “atmosphere” or tone of the person’s answers.
Whether the person is in a sad mood, happy mood, angry mood etc.
5) Speech. The psychologist evaluates the following: a) the volume of the person’s voice b) the rate or
speed of speech c) the length of answers to questions d) the appropriateness of the answers e) clarity
of the answers and similar characteristics
6) Thought content. The examiner assesses what the employee is saying for indications of the
following which are indicative of certain typical disorders. Each of the following will have to be checked
by the learner/ trainee.
7) Thought process. Thought process refers to the logical connections between thoughts and their
relevance to the main thread of conversation. Irrelevant detail, repeated words and phrases, interrupted thinking
(thought blocking), and loose, illogical connections between thoughts, may be
signs of a thought disorder. These can be noted by the psychologist and recorded as and when these
occur.
8) Cognition. Cognition refers to the act or condition of knowing.
9) Judgment. The examiner asks the person what he or she would do about a common-sense problem,
such as running out of a prescription medication. Or ask the person what he would do if he or she
finds a sealed envelope on the road)
10) Insight. Insight refers to a person’s ability to recognize a problem and understand its nature and
severity. (Do you think you are ill? If the person says he or she is not ill and that the family member
who has brought him or her is ill, that shows lack of insight).

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Case History & MSE.pptx

  • 2. 1. Demographic Profile A. Name: B. Age: C. Gender: D. Educational qualification: E. Occupation: F. Income: G. Marital status:
  • 3. 2.Basic Background of the Clients (Q&A Format ) A. Whether client stays with parents: B. Whether client stays with spouse! C. Whether have any siblings, if so, how many; D. What is the position of the client in the family: Eldest, middle or youngest or only child? E. Anyone in the family having conflicts: F. Anyone in the family is suffering/has suffered from any physical disorders
  • 4. 3. Defining Problems (Q&A Format ) • A. Presenting problem: (This should be recorded as the client narrates) • B. Date of onset of the problem: • C. Precipitating factor if any: • D. Duration of problem: • E. Any counselling taken:
  • 5. 4. How intense is the problem and how does it affect the client? (Q&A Format ) A. Has to take leave from workplace / school/college B. Cannot carry on even the routine work C. Does not want to do anything
  • 6. 5. Interview with family members/spouse/the concerned person (Q&A Format) • Their viewpoint in regard to all of the above • The interview with family members should cover all aspects that are covered in the interview with the client.
  • 7. Client’s relationship with family members: • If unmarried: With Mother/ Father /Brothers /Sisters • Any other relative staying with client A. With friends: How many friends does the client have? B. How does the client relate to them? C. With neighbours D. With school and classmates E. With the teachers in school F. With other authority figures G. With playmates H. In the games field
  • 8. 6. Educational history: (Q&A Format) In School/College: • How is the client in studies and academic performance? • Does the client come up to the expectations of parents and teachers? • How has the performance been over the years? • Do they find that there is sudden deterioration in studies and academic performance? • Have they received any complaints from the school authorities regarding the client’s performance? • Since when have they noted that the client is not the same in regard to academics as he or she used to be? • Had they done anything about it so far? If so what? • After their efforts had there been any improvement? • When did they decide to consult a counsellor?
  • 9. 7. Work history: (Q&A Format) • What occupation is the client involved? • How regular is the client for work? • Has the client been complaining about workplace? If so, what? • Generally, how has the client been fairing in work? • What is their perception about client’s relationship in the workplace? With Boss: With colleagues: With subordinates:
  • 10. 8. If Married: (Q&A Format) • Relationship with spouse in terms of • Day to day dealings • Sex life • Work relationship (if spouse is working) • Relationship with children • Relationship with opposite sex persons • Decision making (who takes the decision - spouse or self) • Sharing of work at home with the spouse • Relationship with spouse’s relatives • Relationship with spouse’s friends Record every issue in detail verbatim, that is as is being narrated by the client’s family members.
  • 11. 9. Observation About Client (write in Paragraph format) • Client’s presentation • Client’s personal appearance • Client’s social interaction with office staff and others in the waiting area • Whether the client is accompanied by someone (This helps to determine if the client has social support) • Note the personal grooming • Note things as obvious as hygiene • Note things such as whether the employee is dressed appropriately according to the season • Note if employee is talking to himself or herself in the waiting area • Note if the employee is pacing up and down outside the office door • Record all observations
  • 12. 10. Establish rapport (write in Paragraph format) • By introducing yourself and ask the client’s introduction • Speak directly to the client during the introduction. • Pay attention whether the client is maintaining the eye contact. • Make the client comfortable by offering him a glass of water or talk about the weather outside.
  • 13. MSE (Mental Status of Examination)
  • 14. 1) Appearance. The psychologist notes the person’s age, sex, and overall appearance. These features are significant because poor personal hygiene or grooming may reflect a loss of interest in self care or physical inability to bathe or dress oneself. 2) Movement and Behavior. The psychologist observes the person’s gait (manner of walking, posture, coordination, eye contact, facial expressions, and similar behaviors. Problems with walking or coordination may reflect a disorder of the central nervous’ system. 3) Affect. Affect refers to a person’s outwardly observable emotional reactions. It may include either a lack of emotional response to an event or an overreaction. 4) Mood. Mood refers to the underlying emotional “atmosphere” or tone of the person’s answers. Whether the person is in a sad mood, happy mood, angry mood etc. 5) Speech. The psychologist evaluates the following: a) the volume of the person’s voice b) the rate or speed of speech c) the length of answers to questions d) the appropriateness of the answers e) clarity of the answers and similar characteristics
  • 15. 6) Thought content. The examiner assesses what the employee is saying for indications of the following which are indicative of certain typical disorders. Each of the following will have to be checked by the learner/ trainee. 7) Thought process. Thought process refers to the logical connections between thoughts and their relevance to the main thread of conversation. Irrelevant detail, repeated words and phrases, interrupted thinking (thought blocking), and loose, illogical connections between thoughts, may be signs of a thought disorder. These can be noted by the psychologist and recorded as and when these occur. 8) Cognition. Cognition refers to the act or condition of knowing. 9) Judgment. The examiner asks the person what he or she would do about a common-sense problem, such as running out of a prescription medication. Or ask the person what he would do if he or she finds a sealed envelope on the road) 10) Insight. Insight refers to a person’s ability to recognize a problem and understand its nature and severity. (Do you think you are ill? If the person says he or she is not ill and that the family member who has brought him or her is ill, that shows lack of insight).