The document provides instructions for a clinical intake report assignment in a psychology course, emphasizing the importance of gathering historical background information about an examinee. It details the steps for conducting a clinical interview, including required and optional sections to cover, and specifies elements like treatment recommendations based on biblical principles. Additionally, it outlines a grading rubric and the expected format for submissions.

1. PSYC 421
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.
· 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*****
· Select 4 of the following optional sections of the Clinical

2. 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.

3. · 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.
· This sample document is a comprehensive report and includes
a summary of all of the typical, major elements of a full clinical
interview.
· 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.
· 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.
This assignment is due by 11:59 p.m. (ET) on Friday of
Module/Week 8.
Page 1 of 2
PSYC 421
Clinical Intake Report Grading Rubric

4. Criteria
Description
Points Possible
Points
Earned
Demographic Information
Student summarizes all key demographic data about the
examinee.
10
Initial/General Impressions
Student describes the appearance, attitude and behavior of the
examinee during the clinical interview.
10
Reason(s) for Coming
Student explains the examinee’s reason(s) for coming,
symptoms, and/or complaints.
10
Optional
Section #1
Student clearly labels the 1st optional section of the report, and
provides a comprehensive summary of the examinee’s
responses.
10
Optional
Section #2
Student clearly labels the 2nd optional section of the report, and
provides a comprehensive summary of the examinee’s
responses.
10
Optional

5. Section #3
Student clearly labels the 3rd optional section of the report, and
provides a comprehensive summary of the examinee’s
responses.
10
Optional
Section #4
Student clearly labels the 4th optional section of the report, and
provides a comprehensive summary of the examinee’s
responses.
10
Treatment Recommendations
Student gives at least one example of a Biblically-based
treatment recommendation, and provides at least one scriptural
citation that supports its use.
10
Adherence to Guidelines
Assignment includes APA-formatted title page, header, and
page numbers. It is typed, double-spaced, and 3-6 pages in
length.
10
Writing
Style
Report is well-written in the 3rd-person perspective and uses a
formal, professional tone. Ideas are well- organized, and
writing conforms to all the rules of Standard Written English
grammar, syntax, diction and punctuation.
10
Total
100

6. Instructor Comments:
PAGE
2
BIOPSYCHOSOCIAL ASSESSMENT
CLINICAL INTAKE REPORT
1. DEMOGRAPHIC INFORMATION
2. INITIAL/GENERAL IMPRESSIONS
3. REASON FOR COMING/PRESENTING CONCERNS
4. OPTIONAL SECTION #1 [Place the name of the 1st optional
section that you chose here]
5. OPTIONAL SECTION #2 [Place the name of the 2nd optional
section that you chose here]
6. OPTIONAL SECTION #3 [Place the name of the 3rd optional
section that you chose here]
7. OPTIONAL SECTION #4 [Place the name of the 4th optional
section that you chose here]
8. INITIAL TREATMENT RECOMMENDATIONS
Running Head: CLINICAL REPORT
1
Iman A. Student
Clinical Intake Report
Liberty University

7. CLINICAL REPORT 2
CLINICAL INTAKE REPORT
1. CLIENT DEMOGRAPHIC INFORMATION
Mrs. M is a 31-year-old, married, white female who lives with
her husband of three and a half years.

8. They currently have no children. Her primary language is
English, and her religious affiliation (which
she reports as important to her) is Christianity. As an LPC,
Mrs. M reports earning an annual income
of approximately 50K.
2. INITIAL/GENERAL IMPRESSIONS
Mrs. M is approximately 5’3” and moderately overweight. Her
general appearance was neat and
professional (dress pants and blouse). She was very friendly
and open in her interactions, both
verbally and with her body language. Mrs. M. was actively
engaged in the interview process, and
seemed interested and attentive throughout the entire length of
the interview. She was well-spoken
and appeared to be intelligent. Mrs. M’s facial expressions,
body language and tone of voice
indicated a euthymic and reasonably positive mood throughout
the interview. Of particular note,
however, is that Mrs. M. seemed to laugh at inappropriate times
(e.g., when describing some of her
current frustrations with her husband, when describing the loss
of her older sister, and when
discussing her experiences with sexual abuse as a child).
3. REASON FOR COMING/PRESENTING CONCERNS
Mrs. M has been married for 3.5 years. She reports that the
marriage “is not working”, and that she is
“very unhappy in the marriage.” Her dissatisfaction began
within the first month of marriage when she
began to feel like she “made a mistake” and “rushed into
something that [she] was not ready for.”

9. When asked how she might be contributing to her current
marital unhappiness, she replied, “I said ‘I
do’ before I realized what I was getting into.”
Mrs. M. went on to report that she felt deceived by her husband
because he did things while they
were dating that stopped within the first month after they were
married. When asked for examples,
Mrs. M said, “going to church together, praying together, going
out with friends together, and even
holding a steady job.” Mrs. M reported that when they were
dating, her husband presented himself as
“a motivated, well-rounded person with peer support.” Mrs. M
said that after they married, Mr. M
dropped all of his friends, and she became his “sole
relationship.” She reports feeling pressured to
stay at home with her husband when she would like to be going
out with friends. Further, she says
that Mr. M is resentful when she does go out with her friends.
She says it feels like her husband
“wants her home—all to himself.” Mrs. M also reports that her
husband quit his job soon after they
married, and hasn’t earned a steady income throughout their
marriage. She is deeply unhappy and
frustrated with being the sole financial supporter of the
household.
Mrs. M reports that her marital unhappiness is a severe concern
to her, and it is the primary reason
that she is coming in for counseling. Her marital issues could
end up as a legal issue if the marriage
ends in divorce.
Timeline/History of presenting concern(s): Mrs. M’s marital

10. dissatisfaction began nearly 3.5 years ago,
about 1 mo. after she married. It was at that time that her
husband started acting differently than
when they were dating. Over the first year of the marriage, her
husband began working less and less,
until he finally just quit his job and stopped contributing
entirely to the financial and practical facets of
the marriage relationship. Mrs. M reports that her husband’s
apparent lack of drive and self-respect
has caused her to lose respect for him. According to Mrs. M,
the marriage lacks physical attraction
and emotional intimacy. Her level of personal commitment to
her husband is very low, and the only
thing tying her to the relationship is her desire to “honor God”
by upholding her “marriage covenant.”
Comment [K1]: This sample assignment is
provided only as a guide as you complete your
clinical intake report.
This sample document is a comprehensive clinical
report that includes a summary of all of the typical,
major elements of a full clinical interview.
Your report will NOT be as long as this sample!
Your report will include only 8 sections—the 4
required sections and 4 optional sections that you
chose.

11. Comment [K2]: Required section
Comment [K3]: Required section
Comment [K4]: Required Section
CLINICAL REPORT 3
4. CURRENT AND RECENT SITUATION
As stated above, Mrs. M. currently lives with her spouse. She
also lives with her 2-year-old
Staffordshire terrier, Cooper, whom she calls her “sweet heart”
and “baby boy.” Mrs. M states that
she receives much needed love and affection from her dog.
On a typical day, Mrs. M starts work early at home. She
manages emails and she catches up on
paperwork from her job at counseling agency. About 2 hours
before she needs to report to the
agency, she begins “getting ready.” During that time, she
showers, gets dressed, listens to music,
and reads scripture. She usually arrives at her agency job
between 10:00 and 11:00 a.m. depending
on her client schedule, and she usually remains there until
between 6:30 and 8:00 p.m. On most
days, the people she interacts with most are: colleagues,
associate counselors whom she supervises,
and her site manager (with whom she “consults regularly”),
representatives from other
agencies/service providers, and her clients and their families.
On “less full” work days, Mrs. M
communicates more with friends and family. She reports that at
least twice a week, she goes out for

12. lunch, coffee, etc. with friends, and at least once a week she
goes out with a family member (mom,
dad or brother). Mrs. M’s husband does not like to do social
things and refuses most of her requests
to go out. Mrs. M reports that, at most, he will agree to go out
for a quick dinner, and then wants to
rush back home.
Over the past year, Mrs. M has experienced several significant
changes that may have contributed to
her current marital dissatisfaction. First, Mrs. M has been
promoted at her job from an intensive, in-
home counselor to an outpatient, on-site counselor. This
promotion has affected her marriage in
several ways. She wants to go on vacation to celebrate, but her
husband refuses, which frustrates
Mrs. M. An increase in workload has resulted in a decrease in
communication, and the remaining
communication “completely lacks intimacy” and is mostly about
the business end of marriage.
Second, Mrs. M and her husband have experienced the loss of
loved ones. Most of the loss has been
on Mr. M’s side of the family so it has affected him more than
Mrs. M. As a result of the loss, Mr. M
has become increasingly depressed (e.g., he sleeps all day, and
plays video games or watches TV at
night). Finally, Mrs. M just bought a house and moved. This
change contributes to the financial
stress on the marriage. Mrs. M says that she is resentful
because she carries all of the financial
“stress/burden” for the couple because Mr. M doesn’t work.
She has purchased everything for the
new house, and “supports all of his needs and wants.” She goes
on to say that he doesn’t even take
initiative to take care of the new house. In addition to working,

13. she takes care of almost all household
chores. Mrs. M has to ask her husband repeatedly to take care
of a chore (e.g., cutting the grass),
and he usually only will follow through when she “threatens” to
turn off the cable or internet. Since
buying the house, Mrs. M reports that being married is more
like “having a child than a husband.”
When asked how she has tried to handle the problem so far, she
said that she has separated from
him multiple times. Once, she even lived in her car for 2
months. During those times, she tried
talking to him about her dissatisfaction. He would promise to
change if she came back. Things would
change for a week or so, but then the situation would be “worse
than before—like a downward spiral.”
Mrs. M also has tried “threatening” with loss of privileges (e.g.,
cable, internet, car use), but that only
works for the immediate. She said she has tried “encouraging,
inspiring and uplifting,” but he did not
respond. She also reports trying prayer, but is discouraged
because she has seen no change.
When asked what strengths she has that have helped her to
manage this difficulty so far she listed
several. She said that she enjoys work, so she will go to work to
increase her happiness. She says
that she is patient because “3.5 years is a damn long time.” She
says that she tries to stay optimistic
and think positively, but she says she also needs to be realistic.
Mrs. M has several sources of support for her current problem.
She reports that most of the time
when she is feeling upset about her marriage, she goes off by

14. herself and “takes some time” to be
Comment [K5]: Optional section
CLINICAL REPORT 4
alone. She also relies on God for comfort through prayer and
worship. When she wants to “bitch and
complain” or when she feels like she is “about to explode,” she
talks to family and friends. So for her
day-to-day frustration and sadness, she turns to God, but when
things come to a head, she turns to
family and friends.
Since the problems with her marriage began, Mrs. M has
experienced changes in functioning.
Physically, she feels exhausted and has no energy.
Emotionally, she often retreats into herself, and if
she “hyper-focuses” on her marriage situation, then she will feel
depressed. Cognitively, she has a
difficult time concentrating. Behaviorally, she says that she has
to work extra hard to compensate for
her husband. Mrs. M added that she is “in a beautiful place
personally and professionally” so she
doesn’t feel depressed overall. She is simply unhappy about a
specific aspect of her life. So outside
of her marriage, everything appears to be going well for Mrs.
M.
5. PREVIOUS ASSESSMENTS AND COUNSELING
EXPERIENCES
Mrs. M reports that she received vocational testing and
educational testing while she was a junior in

15. college. Testing indicated that she has a “reading
comprehension disability” and that she was
“comprehending at a 7
th
grade level.” Mrs. M also reports having psychological testing
at that time to
assess for clinical syndromes like personality disorders, mood
disorders, and anxiety disorders. She
did not recall which specific tests were administered.
Mrs. M reports that she has been in counseling before. She
sought out counseling on her own
because she was distressed by how she felt and because she had
decided to pursue counseling as a
career, and “knew that [she] needed to make significant changes
in her life” in order to do so. She
started in counseling in 2006, and she currently is still in
counseling with the same therapist.
With her therapist, she has tried CBT techniques (e.g.,
relaxation, meditation), reality therapy,
art/music therapy, Sand Tray therapy, and behavior
modification techniques. In addition, she has
agreed to increases in level of care (i.e., in-patient treatment)
when needed. Regarding the outcomes
of these interventions, she believes that her mood and
functioning have improved significantly overall,
though she still feels that she has work to do.
Mrs. M has received several diagnoses in the past, including:
ADD, PTSD, MDD, GAD, and
Substance Use Disorder (alcohol, marijuana, nicotine and
caffeine). She also has been prescribed

16. Lexapro, Celexa, Wellbutrin, and Seroquel; GAD
Xanax, Ativan, Paxil and Zoloft. None
of these medications helped with her symptoms, and she
experienced severe side effects including
auditory hallucinations and suicidal ideations. In 2007, Mrs. M
made a suicide attempt (that resulted
in a coma) using a benzodiazepine that she had been prescribed.
She began by taking one pill to
control feelings of anxiety, but ended up taking the entire bottle
in order to “drown out the voices in her
head.”
6. BIRTH AND DEVELOPMENTAL HISTORY
When Mrs. M was born, her mother was 23 years old and her
father was 27 years old. They were
married at the time, but divorced when Mrs. M was a child. The
pregnancy was not planned, as Mrs.
M’s mother actually had a tubal ligation after the birth of her
second child. The pregnancy went to
term and was uncomplicated. Mrs. M believes that her mom
received prenatal care, but she is not
sure. Before she knew she was pregnant, Mrs. M’s mother
smoked cigarettes and marijuana. When
she found out she was pregnant, she stopped smoking
marijuana, but continued smoking cigarettes.
At birth, Mrs. M was 6 lb. 12 oz. At birth, Mrs. M had both a
heart murmur and an atrial septal defect
(i.e., a hole in the part of the septum that separates the upper
chambers of the heart). Because of this
Comment [K6]: Optional section
Comment [K7]: Optional section

17. CLINICAL REPORT 5
heart defect, Mrs. M had emergency heart surgery immediately
after she was born. Mrs. M reports
that her delivery was “normal,” but she needed oxygen, had
difficulty breathing, and turned blue
because of her congenital heart defect.
Regarding childhood developmental issues, Mrs. M reported the
following: 1) overactive, 2) sleep
problems, 3) anxious/perfectionistic, 4) depressed, 5) shy, 6)
easily frustrated, 7) nightmares, 8) fears/
phobias, 9) poor appetite and 10) attention problems.
When asked if there was any other information about her
childhood that we did not cover and that she
would like to share, Mrs. M disclosed that she was both
physically and sexually abused by multiple
people when she was a child. When I asked if she would mind
sharing some details about her
experiences, she agreed. Mrs. M said that the sexual abuse
began when she was 4 years old by her
maternal grandfather. Next, she was abused when she was 5
years old by her maternal uncle who
came to stay with Mrs. M’s family for a short time. Also at age
5, a maternal cousin (though not the
child of the uncle previously mentioned) also sexually assaulted
her. The majority of the abuse was
perpetrated by her paternal grandmother who lived with the
family and by her brother. Her paternal
grandmother abused her from age 6-14. The abuse stopped
when her grandmother died. Her
brother, at the prompting of their paternal grandmother, abused
her from age 6-16. The abuse by her

18. brother stopped only when Mrs. M pulled a knife on him.
7. FAMILY OF ORIGIN/FAMILY CONSTELLATION
Mrs. M’s father is 59 years old. He has a high school
education. He has no known academic
problems and no diagnosed emotional problems. He does have
various medical problems, including:
a recent stroke, overweight, pre-diabetes, and high blood
pressure. Mrs. M reports having “a weird
relationship” with her dad because their “personalities are so
much alike.” She says that she even
looks like him. Mrs. M says that they get along fairly well
because they both are “passive.” He often
asks Mrs. M if he can borrow money, and she has always given
it to him in the past when he has
asked. Mrs. M stopped taking her father’s calls about two
weeks ago after she bailed him out of jail
for writing bad checks.
Mrs. M’s mother is 55 years old. She has an Associate’s
degree. She has no known academic
problems and no diagnosed emotional problems. She does have
various medical problems,
including: heart attack, congestive heart failure, high blood
pressure and emphysema (due to
smoking). Mrs. M says that she and her mother have very
different personalities. This difference
caused relationship problems when Mrs. M was an adolescent,
but now they are “quite close, and talk
about all kinds of stuff.” Mrs. M says that her mother is clingy
and dependent. Mrs. M gets annoyed
with her mother and they fight when Mrs. M’s mom “plays the
helpless victim role.” Her mom does not
ask directly for money. Instead, “she hints around,” and if “you
don’t give into her hint, then she gives

19. a guilt trip and plays mind games” which annoys and
exasperates Mrs. M.
Mrs. M had a sister, Ms. T, who died at age 5. Ms. T would be
36 right now if she were living. When I
asked if she would mind sharing details of her sister’s death,
Mrs. M explained that their father had
run Ms. T over with a truck while driving drunk. Mrs. M has no
memory of her sister as she was an
infant when Ms. T passed. Mrs. M says that her family never
talks about Ms. T, and that there aren’t
even any pictures of her at home or in albums. She says that
they “swept it under the rug like nothing
ever happened” which is “what [her] family does with
everything.” (By this, I suspect that she might
have been referring to the sexual abuse that she experienced.)
Mrs. M has a brother, Mr. C., who is 34 years old. This is the
brother who sexually abused Mrs. M at
the prompting of their paternal grandmother. Mr. C has a
Bachelor’s degree in accounting. He has
no known academic difficulties (except for trouble with
spelling), no medical problems, and no
Comment [K8]: Optional section
CLINICAL REPORT 6
diagnosed emotional problems. Mrs. M reports having a “good
relationship” with her brother despite
the years of abuse. They get together regularly for coffee or
lunch. When discussing her brother,
almost as a side note, Mrs. M laughingly told me that he is gay.

20. When asked if there were difficulties at home not yet
mentioned, Mrs. M explained that her parents
divorced when she was a child, and both remarried other people
when she was an adolescent. Mrs.
M’s mom “bailed out” on the family and left the state to go to
college. Care for Mrs. M shifted to her
dad and paternal grandmother (who abused her).
When asked what changes at home would have made life easier
for her she mentioned two things:
1) if her paternal grandmother never came to live with them and
2) if her parents/the family could have
communicated better. She further explained that her family is
“too secretive,” that nothing was ever
talked about until it hit a “boiling point” when “anger came out”
and “nothing was ever solved.”
8. EARLY RECOLLECTIONS
Early Memory #1: Mrs. M remembers being spanked by her
paternal grandmother and being placed
on the floor with a playpen over top of her so that she “could
not get out.” She remembers sitting
there crying and feeling angry because she “wasn’t sure what
she did wrong, but didn’t deserve what
happened.”
Early Memory #2: Mrs. M remembers going to church as a child
and “loving it.” She remembers
being really involved. She remembers the pastor and his wife
driving to pick her up and drop her
before and after church on Wednesdays and Sundays after her
parents “quit going.” She remembers
feeling happy and feeling good learning about God. She also
remembers feeling sad that “her
parents didn’t want to go with her.”

21. 9. MARITAL AND FAMILY DATA
Mrs. M is has been married to Mr. M (31 years old) for 3.5
years. Mr. M has a high school diploma.
He had learning difficulties in school that were made worse by
the medication that he took to manage
his ADHD. Mr. M has asthma, and uses an albuterol inhaler.
Regarding emotional problems, Mr. M
was diagnosed with ADHD as an adolescent. Though he never
has been diagnosed by a clinician,
Mr. M has told Mrs. M that he feels depressed nearly all the
time.
10. MEDICAL HISTORY
Major Injuries, illnesses, and surgeries: Mrs. M was born with a
heart murmur and with an atrial septal
defect which required immediate, emergency surgery. In 2005,
Mrs. M had appendicitis/
appendectomy. In 2009, Mrs. M deliberately overdosed with
alcohol and 30, 0.5 mg Ativan tablets.
Her heart stopped and she had to be resuscitated multiple times
before she went into a coma. In
2011, Mrs. M had her tubes tied.
Medications: N/A
Regarding current/past medical history, Mrs. M reports the
following: 1) seasonal allergies, 2) extreme
fatigue much of the time, likely due to overworking, 3)
dizziness, 4) stomachaches, 5) tremors,
6) headaches, 7) sleep problems since adolescence (takes
melatonin as needed), 8) memory
problems that started after the coma in 2009, 9) kidney
problems occurred as a result of the coma,

22. she received dialysis twice, but hasn’t had problems since then,
10) history of bronchitis and
pneumonia, perhaps because of asthma, 11) congenital heart
problems, 12) ongoing attention
Comment [K9]: Optional section
Comment [K10]: Optional section
Comment [K11]: Optional section
CLINICAL REPORT 7
problems since childhood, 13) went into drug treatment rehab
after overdose/coma. Other conditions
include: carpal tunnel syndrome and ongoing heart issues.
Regarding family medical history, Mrs. M reports: Brother: had
repeated ear infections as child. Mom:
seasonal allergies, heart disease, sleep problems, migraines,
pneumonia, heart attack, tremors, and
high BP. Dad: seizures, heart attack, heart disease, neurological
issues, heart problems, high BP,
and attention problems.
11. EDUCATION AND TRAINING
Mrs. M’s educational history confirms my impression of her as
intelligent, articulate and professional.
She earned a B.S in Psychology and an M.A. in Community
Counseling. Then she earned an Ed.D.
(highest degree earned) in Counseling Psychology with a
concentration in Counselor Education and
Supervision.

23. Regarding her performance and preferences in school, Mrs. M.
says that reading, writing, and science
were the easiest subjects for her, as well as the ones she enjoyed
the most. The subject that was
most challenging for Mrs. M was math. Her greatest source of
pride throughout her schooling has
been her writing performance. Mrs. M says that she always has
had an “above average” attitude
toward school. Given the turmoil of her home life as a
child/adolescent, school was a place where
she could “feel free” and “do well.”
Mrs. M says that she was never retained in grade placement and
that she never received an IEP, BIP
or 504 accommodation plan. Although she was diagnosed with
a “reading comprehension disability”
as a junior in college, she chose not to receive any
accommodations.
12. WORK BACKGROUND/HISTORY
Right out of her M.A. program, Mrs. M had a job as a middle
school guidance counselor, and then as
a high school guidance counselor. While she “loved” the
middle school age group and “liked” the high
school age group, she found that she wanted to do more
clinical/counseling work. So she left her
school job because she wanted to do more work directly in the
community and because she decided
to pursue licensure as a LPC (which she has completed at this
point).
Mrs. M also worked as an In-Home Intensive Therapist and
Team Lead. Mrs. M really enjoyed
working with the families and helping people change for the

24. better (especially children), but she “hated
driving around.” As a team lead, she has good working
relationships with the QP’s (qualified
professionals) on her team, but she was concerned about how
“dependent” they were on her and how
they seemed to lack “confidence to make decisions on their
own.” She was promoted from this
position to the clinical position that she currently holds.
Mrs. M currently works as an Outpatient Therapist/Assistant
Clinical Director, which she enjoys
immensely. The aspects of her work that Mrs. M enjoys best
are: 1) helping people and teaching
clients new skills, 2) teaching future counselors how to be
counselors, 3) feeling like she “is living [her]
purpose and doing what God called [her] to do.” The aspects of
her work that Mrs. M enjoys least
are: 1) paperwork, 2) meetings, and 3) “basically all
administrative tasks.”
Comment [K12]: Optional section
Comment [K13]: Optional section
CLINICAL REPORT 8
13. RECREATION, INTERESTS, AND PLEASURES

25. Mrs. M enjoys a variety of recreational activities that appear to
tend to her body, mind/emotions and
spirit. She enjoys playing with and walking her dog, walking in
nature, and going to the beach. Mrs.
M also enjoys listening to encouraging messages by spiritual
leaders, reading the Bible, listening to
uplifting music, and praying/meditating. She also works out,
rides bikes, goes bowling, goes dancing,
and plays recreational sports (e.g., volleyball, basketball, and
kickball).
While Mrs. M has many areas of pleasure/interest, she doesn’t
get to engage in them as frequently as
she would like because of her “busy work schedule.” She does
try to make time for recreation at least
once or twice a week.
14. SOCIAL SUPPORTS, COMMUNICATION NETWORK,
AND SOCIAL INTERESTS
Mrs. M says that she has several excellent sources of social
support/social interest.
s “from a distance who [she] loves and
adores and speaks to quite frequently
by text, phone and email.” They can talk about anything and
everything—“good stuff, challenges,
problems, whatever.”
things.
supervisors who are “able to help [her] with
cases, job responsibilities, licensure requirements etc.

26. increase her self-esteem and to
decide “what she wants and where she wants to go next” in life.
She also is using coaching
services in thinking about and planning for her own private
practice.
with whom she continues to work
“quite frequently.” Mrs. M appears to be basically satisfied
with the therapeutic relationship that
she has created with her counselor as well as with the progress
that she has made. I got the
sense that Mrs. M wasn’t completely satisfied with the services
she has received so far, but she
indicated that it would be “too difficult to start [the process]
again with someone else.”
15. SELF-DESCRIPTION
When asked about her strengths, Mrs. M listed the following: 1)
perseverance, 2) willingness to learn/
grow/change, 3) passion for her work and for serving other
people, 4) being a good person, 5) being
kind-hearted. When asked about her weaknesses, Mrs. M listed
the following: 1) low self-esteem,
2) sometimes letting her “fears get the best of [her],” 3) being a
“work-a-holic.”
Mrs. M then offered the following explanation for her tendency
to be work-a-holic—“Work is a way for
me to disconnect from the negative in my life and to connect
with something positive.” Because Mrs.

27. M enjoys her work and believes that she is good at what she
does, it appears that work may function
as a safe place amidst the chaos and sadness of her personal
life. She also said that because of her
health problems, she is afraid that she may not live long enough
to accomplish all the goals that she
has set her mind to.
Mrs. M provided the following self-description: “I am very
creative. I love music, art, dance, writing,
and just playing like a kid. I also use creative interventions in
my work with children, adolescents,
adults and families. I often visualize the beach or some kind of
nature/water to help reduce anxiety
and tension, or even to help me battle my depression from time
to time. I also try to visualize what
heaven might be like or what God might look like.”
Comment [K14]: Optional section
Comment [K15]: Optional section
Comment [K16]: Optional section
CLINICAL REPORT 9
16. CHOICES AND TURNING POINTS IN LIFE
In her senior year of high school, Mrs. M was robbed at

28. gunpoint while at work as a cashier. At that
point, she decided to go to college to “get out of that
environment.” This decision completely changed
the course of her life as she never even thought of going to
college before then. College was not
something that her family “modeled” or thought of as important.
In the first two years as an undergraduate student, Mrs. M failed
and re-took 14 classes. Because of
these failures, Mrs. M realized that she had a learning disability
which she began to work hard to
overcome. She also changed majors, which “changed the course
of [her] life,” and put her on a path
“more in-line with [her] purpose and calling.”
After earning her BS is psychology, Mrs. M decided to “go
lateral entry into teaching special
education. When she started teaching, she realized that she had
“a passion for teaching and helping
others.” The work was “new, and hard, and [she] felt like [she]
was totally out of [her] element.” She
never had taught a single class in her life when she “stepped in
front of a classroom full of 8
th
graders.” In her feelings of lack, she realized that “God could
use her to amazing things” even when
she “knew very little.” Mrs. M was very proud and excited to
earn the “Rookie of the Year” teaching
award her first year as a special education teacher.
While in graduate school, Mrs. M decided to enter therapy.
According to Mrs. M, therapy has had its
“ups and downs, and at first it was all downs/bad.” After years

29. of therapy and “a lot of hard work,”
Mrs. M says that she is “starting to see the fruits of all the
effort [she has] put in. Therapy has helped
her develop as a counselor.
After her suicide attempt/overdose/coma in 2009, Mrs. M
entered rehab where she was able to see
firsthand the consequences of a life of drug abuse. Both her
roommate and another young man died
right in front of her. At that point, she realized that she did not
want that outcome for her life. Being in
rehab gave her to opportunity to distance herself from the
negative influences and environments in
her life and to really focus on herself instead of “trying to take
care of the world.” Her experiences in
rehab helped her to realize that she “was worth so much more”
than she thought of herself and that
she wanted to live.
The choice to pursue a doctorate and to believe that she could
contribute to the world by teaching
future counselors has provided Mrs. M with a sense of both
personal and professional fulfillment.
Mrs. M says that she has overcome many obstacles to get to
where she is now—a counselor and an
assistant professor of counseling. She derives personal and
professional satisfaction from the fact
that she achieved her dream despite great adversity and that she
is meaningfully contributing to
society by teaching others to do the work about which she is so
passionate.
17. PERSONAL GOALS AND VIEW OF THE FUTURE
In the next year, Mrs. M would like to see the following

30. happen: 1) get the Distance Credentialed
Counselor (DCC) certificate through the National Board of
Certified Counselors (NBCC), 2) look for
new employment opportunities, 3) possibly take a new job offer,
4) possibly relocate to Portland, OR.
In the next 5 years, Mrs. M would like to: 1) Obtain her
Approved Clinical Supervisor (ACS) credential
through the NBCC and begin supervising provisionally licensed
counselors, 2) have her own private
practice, 3) teach graduate school full-time.
In the next 10 years, Mrs. M would like to: 1) be a published
author, 2) be teaching full-time, 3) have a
thriving private practice, 4) be a motivational speaker, and 5)
travel the world.
Comment [K17]: Optional section
Comment [K18]: Optional section
CLINICAL REPORT 10
Mrs. M believes that she already is taking the steps that she
needs to in order to accomplish all of her
goals. She says that she just needs to continue to do more of
the same thing. Mrs. M also says that
she believes her marriage relationship in its current state is an
impediment to achieving all of her
dreams and goals. She believes that her husband’s “complete
lack of motivation” is holding her back
from achieving her own goals. She “fears” that severing the

31. relationship might be a necessary step
for her “to move forward with her life.”
18. INITIAL TREATMENT RECOMMENDATIONS
1) Additional psychological testing is recommended to
determine the continued presence and
severity of other symptoms/clinical syndromes not revealed by
the current case history and to
further elucidate Mrs. M’s presenting concerns.
2) Continued individual therapy on a once-weekly basis, with
either her current therapist or a new
therapist is recommended. Therapy should focus on Mrs. M’s
presenting concerns around her
relationship with her husband and on increasing Mrs. M’s
ability to manage her negative cognitive
and emotional responses to her marital situation.
3) Couples’ therapy may be warranted in the future, but Mrs.
M’s husband presently refuses to attend
counseling, and Mrs. M has little motivation to work on the
relationship.
4) Because Mrs. M’s spiritual beliefs play such a significant
role in her life, effort should be made to
incorporate these beliefs into treatment planning.

32. Comment [K19]: Required section
IMPORTANT NOTE: It is here in your Clinical
Intake Report that you will make at least one
Biblically-based treatment recommendation which
you will logically support with the use of at least one
relevant scriptural citation.
1
CLINICAL INTERVIEW/CASE HISTORY
1. DEMOGRAPHIC INFORMATION
Name: DOB: Age: Sex:
Address: Home Phone:
Work Phone:
Email Address: Cell Phone:
Marital Status: Race/Ethnicity: Religion:
Income: Occupation: Language(s):
2. INITIAL/GENERAL IMPRESSIONS OF CLIENT
Appearance:
Attitude:
Behaviors:
3. REASONS FOR COMING/PRESENTING CONCERN(S) (As

33. stated by person/family)
(Include reason(s) for coming in, symptoms or complaints,
including whether or not the complaint is the result
of or is likely to end up as a legal issue)
WHAT is/are the problem(s)? WHEN did it start? HOW is the
problem displayed?
HOW serious are these concerns to you?
NOT A CONCERN SLIGHT MILD
MODERATE SEVERE EXTREME
Is this problem likely to end up as a legal issue? If yes, please
explain:
Additional Comments:
4. CURRENT AND RECENT SITUATION
Where do you live, and with whom?

34. Describe to me a typical day of yours. Where do you go, and
who do you see most days?
2
Over the past year, have you experienced any significant life
changes? Please tell me about them? Do
you think these changes have contributed to the problems that
you are experiencing?
How have you tried to handle the problem so far?
What has worked, even if just a little bit?
What hasn’t worked?

35. What strengths do you have that could help or have helped you
overcome this difficulty?
Who can you rely on for support with this problem?
Since this problem began, what changes in functioning have you
noticed in the following areas?
Physical/Health:
Emotional:
Thoughts:
Behaviors:
Learning:
5. PREVIOUS ASSESSMENTS AND COUNSELING
EXPERIENCES
Have you ever been tested for a psychological, educational or
career reason?
If so, please explain:
If so, do you know which tests and the approximate dates that
they were administered?

36. 3
What were the results of the test(s)?
Have you ever received counseling services before? If so,
explain what led to initiation of
these services.
What interventions were attempted?
What were the outcomes of these interventions?
Have you ever been diagnosed with a mental or emotional
disorder?
If so, which one(s)?
Have you ever been prescribed medication to treat a mental or
emotional disorder?
If so, which one(s)?

37. 6. BIRTH AND DEVELOPMENTAL HISTORY
Do you know how long your mother’s pregnancy with you
lasted?
Do you know if the pregnancy was planned?
Type of Labor? (circle one) Easy Moderate Difficult
Length of Labor?
Mother’s age at birth? Father’s age at birth
Month prenatal care began (circle one): None 1
st
2
nd
3
rd
4
th
5
th
6
th
7
th
8

38. th
9
th
Baby was born: Full term weeks early weeks late
Baby’s condition, height and weight at birth?
Did the mother smoke, drink alcohol, take street drugs or use
prescriptions medications during
pregnancy? If so, please explain
Birth Characteristics (check all that apply):
____ Normal delivery ____ Breach delivery ____ Caesarian
delivery ____ Induced delivery
____ Forceps delivery ____ Needed oxygen ____ Cord around
neck ____ Was a twin
____ Infection ____ Injured (specify) ____ Difficulty breathing
____ Turned blue
____ Jaundiced ____ Seizures ____ Trouble sucking ____
Breastfed
____ Diarrhea ____ Vomited often ____ Constipated ____
Given medication
____ Birth defect (specify) ____ Sleepy/listless ____ Difficulty
nursing ____ Blood transfusion
4

39. Childhood Developmental Issues (check all that apply):
____ Late walking ____ Late crawling ____ Attention problems
____ Overactive
____ Late talking ____ Seizures ____ Late toilet training ____
Bed wetting
____ Sleep problems ____ Defiant ____ Anxious/perfectionistic
____ Depressed
____ Aggressive ____ Clingy ____ Truant ____ Delayed math
____ Delayed reading ____ Shy ____ Frequent tantrums ____
Retained in school
____ Poor coordination ____ Easily frustrated ____ Impulsive
____ Poor handwriting
____ Nightmares ____ Frequent crying ____ Fears/phobias ____
Poor appetite
____ Speech problems ____ Soiling of pants ____ Difficulty
separating from parent(s)
Additional Comments:
7. FAMILY OF ORIGIN/FAMILY CONSTELLATION
For your biological family, please provide:
Academic Medical Emotional
Name Age Education Problems Problems Problems
Father: Yes No Yes No Yes No
Mother: Yes No Yes No Yes No
Siblings/Other: Yes No Yes No Yes No
Yes No Yes No Yes No
Yes No Yes No Yes No
Yes No Yes No Yes No
Yes No Yes No Yes No
Yes No Yes No Yes No

40. Please provide details about any family academic, medical or
emotional problems indicated above.
Academic:
Medical:
Emotional/Psychological:
Describe your relationships with key family members:
How were rewards and punishments carried out in the home?
Were there difficulties in the home not yet mentioned? If so,
explain:
5
What changes at home would have made life easier for you?

41. Is there anything else about your family life that we’ve left out
and you’d like to tell me about?
8. EARLY RECOLLECTIONS
(Describe people, place(s), events, overall emotional feel of
your three earliest memories)
Early Memory #1:
Early Memory #2:
Early Memory #3:
9. MARITAL AND FAMILY DATA
If you are married, please provide the following information:
Academic Medical Emotional
Name Age Education Problems Problems Problems
Spouse: Yes No Yes No Yes No
Child #1 Yes No Yes No Yes No

42. Child #2 Yes No Yes No Yes No
Child #3 Yes No Yes No Yes No
Child #4 Yes No Yes No Yes No
Yes No Yes No Yes No
Yes No Yes No Yes No
Yes No Yes No Yes No
10. MEDICAL HISTORY
Tell me about all major injuries or surgeries and the
approximate age of occurrence:
Are you taking any medications for medical conditions? If so,
please list them:
6
Indicate all that apply to your current or past medical history:
____ Ear infections ____ High fevers ____ Trouble hearing
____ Trouble seeing
____ Allergies ____ Asthma ____ Kidney problems ____ Heart
problems
____ Seizures ____ HIV/AIDS ____ Pneumonia ____ Bronchitis
____ Meningitis ____ Numbness/tingling ____ Stroke ____
Coma
____ Head injury ____ Sleep problems ____ Heart attack ____

43. High BP
____ Heart disease ____ Angina ____ Anemia ____ Lead
poisoning
____ Extreme fatigue ____ Memory problems ____ Tremor
____ Attention problems
____ Dizziness ____ Headaches ____ Stomachaches ____ Drug
treatment program
____ Diabetes ____ Cancer ____ Neurological issues ____
Poisoning/Overdose
Please provide additional information for all of the items
checked above:
What additional conditions or illnesses have you had or do you
currently have?
Has any member of your family been diagnosed with any of the
following (check all that apply)?
____ Ear infections ____ High fevers ____ Trouble hearing
____ Trouble seeing
____ Allergies ____ Asthma ____ Kidney problems ____ Heart
problems
____ Seizures ____ HIV/AIDS ____ Pneumonia ____ Bronchitis
____ Meningitis ____ Numbness/tingling ____ Stroke ____
Coma
____ Head injury ____ Sleep problems ____ Heart attack ____
High BP
____ Heart disease ____ Angina ____ Anemia ____ Lead
poisoning

44. ____ Extreme fatigue ____ Memory problems ____ Tremor
____ Attention problems
____ Dizziness ____ Headaches ____ Stomachaches ____ Drug
treatment program
____ Diabetes ____ Cancer ____ Neurological issues ____
Poisoning/Overdose
Please provide additional information for all of the items
checked above:
Additional Comments:
11. EDUCATION AND TRAINING
List names and grades attended for all schools and colleges:
What is the highest grade/diploma/degree achieved?
What subjects were the easiest?
7
What were your favorite subjects to study?

45. What subjects were the most challenging?
What were some areas of pride? Difficulty?
Did you receive any special services (e.g., IEP, BIP or 504
plans)? If so, please describe?
How was you attitude toward school? (Circle one)
Excellent Above Average Average Below
Average Poor
Were you ever retained in grade placement? If so, when?
Additional comments:
12. WORK BACKGROUND/HISTORY
List all of the jobs that you have held in the last five years?
Describe each job and your level of satisfaction with each:
What factors caused you to leave the jobs listed above?

46. If you are currently employed, what is your current job title and
description?
How long have you had this job?
What is your level of satisfaction with your current work?
Low Average High
What aspects of your work do you like best and why?
What aspects of your work do you like least and why?
8
13. RECREATION, INTERESTS, AND PLEASURES
Describe your interests, recreational activities and things that
you do for please (e.g., reading, playing sports).
Include any volunteer work that you do.

47. 14. SOCIAL SUPPORTS, COMMUNICATION NETWORK,
AND SOCIAL INTERESTS
Describe the people that you talk to most frequently, the people
available to you for various kinds of help, the
amount and quality of interactions that you have with people,
and your sense of contribution to others and to
the community.
15. SELF-DESCRIPTION
Describe yourself, including: your strengths and weaknesses,
your ability to be creative and use imagery, your
values and ideals, and anything else that you think is important.

48. 9
16. CHOICES AND TURNING POINTS IN LIFE
Describe the most important decisions and choices that you
have made in your life. Discuss the impact of
each choice. Identify the single most important decision/choice
you have made, and explain why it is
important.

49. 17. PERSONAL GOALS AND VIEW OF THE FUTURE
Describe what you would like to see happen in your life in the
next year, the next 5 years, and the next 10
years. Describe what is necessary for these events to happen.
18. INITIAL TREATMENT RECOMMENDATIONS
(THIS SECTION IS FOR INTERVIEWER USE ONLY. DO
NOT ASK EXAMINEE ABOUT TREATMENT
RECOMMENDATIONS.)