Summarized clinical report writing

Outline for an Unstructured Clinical Interview Format

The chief feature of the unstructured interview is the idea of probe questions aimed at
determining the client’s reason for being in treatment, symptoms, health status, family
background, and life history that are designed to be as open as possible.

A typical clinical interview will cover:

 Age and Sex

 Reason for referral
 Developmental history
 Education and work history
 Current social situation
 Physical and mental health history
 Drug/alcohol use and current medication
 Family history
 Behavioral observations

Among others/ e.t.c.

This is Example of a simple clinical interview that combined with counselling sessions.

For a more detailed clinical interview please consult the powerpoint notes sent to your email.

PROGRESS NOTES FOR GODFREY

The sessions took place at XYZ hospital

Date of 1st session: 16.5.2016

NB: Godfrey was referred for therapy by his guidance and counseling teacher.

BACKGROUND INFORMATION:

Gender: Male

Age: 29 years

Nationality/ethnic background/ location: (name ethnic group)/( name County)

Education Level: College continuing

Occupation: Student

Marital status: Single.

Family & Developmental history: Godfrey reported that he was the 3rd born in a family of 8
siblings. He had 3 brothers and 4 sisters. His mother died of cancer of the throat in 2014. He
described his early childhood as quite uneventful till the father started marrying other women
and the family became disorganized. Though he was bright in school and scored 398/500 in
KCPE in 2002, and was admitted to a national school, the parents could not take him there so he
went to a day school near his home. He was angry and engaged in vices that landed him in police
cells many times. He sat his KCSE in 2007 and scored a C+ of 54 points. His father is
polygamous and promiscuous; his mother was the 1st wife. One of the wives run away and he had
one left. The mother was a chang’aa brewer and was frustrated by her husband to a point of
sleeping with her customers. He was requested by his siblings to chase the men away; for this he
was at loggerheads with his mother who used to curse him but she blessed him when she visited
him in prison in 2013 just before her death.

He had attended (name of college) College in Nairobi in 2011 but dropped out after 1 term
before sitting his exams. His elder brother who believes in him paid the fee and he still pays his
college fee. He had dated several women but he was currently in a turbulent relationship.

Previous medical history: Godfrey reported that he had no history of major illness.

Previous Legal history: Godfrey engaged in several vices like stealing, fighting in public,
drinking and verbal abuse and was arrested several times. In 2012, he was arrested and
incarcerated for 1 year till November 2013.

Previous psychiatric history:

There was a family history of alcohol use disorder. He reported that his late mother and her
family of origin drunk a lot of alcohol. His mother was a chang’aa brewer and he had started
drinking at a very early age. In addition to alcohol, he became frustrated with life and smoked
bhang and cigarettes between 2007 and November 2015.

Presenting problem (s): Godfrey was referred because he had psychological disturbance. He
reported that he had disagreed with his girlfriend in February 2016 and that had negatively
impacted his life. For the respect of this girl he had stopped using drugs and their relationship
was not sexual. He was also sad because he had hugged other women to irritate her every time
they disagreed. In March 2016; when he came near her she rung another young man to come for
a hug in his presence. Though Godfrey had slapped the young man, he realized that he was
driving the girl to doing what his father drove the mother to do. This made him sad. He reported
loss of appetite since March 2016; he had even fasted for 21 days in April 2016. He reported
crying and disturbed sleep most of the time. He also reported little concentration, feelings of
worthlessness, depressed mood most of the day, nearly every day, diminished interest, and loss
of energy. He was not suicidal.

DSM 5 Diagnosis:

1. Major Depressive Disorder, severe, single episode, with melancholic features 296.23
(F32.2).
2. Alcohol use disorder, in early remission 303.90 (F10.20) severe
3. Tobacco use disorder, in early remission 305.1 (F17.200) severe
4. Cannabis use disorder, in early remission 304.30 (F12.20) severe

Treatment Plan:

Reality Therapy: Reality check on what he was going through.

Assessment of depression using BDI yielded a level of 6 which is normal mood disturbance. He
indicated the 7 symptoms of MDD as being present for at least 4 months. He reported that he had
gone home over the weekend (12-15th May 2016) and calmed himself through reflection on his
life. Hence the low scores on BDI.

Session 2: 1.6.2016

A review of his symptoms revealed that they had dissipated. He and the girl were still avoiding
each other. He however, had tried not to go back to drugs and he had managed without them. He
focused on what we had discussed in our last session. He took care of himself through prayer and
going back to his daily training programme.

Session 3: 11.6.2016

Pre-termination: Godfrey reported that he had been coping well and that he had taken the girl as
God sent to help him stop the drug taking habit. He felt that he could cope without therapy and
use the skills learned. Termination was discussed.

Session 4: 18.6.2016 Termination

Godfrey was able to tabulate the skills and knowledge that he had gained in therapy. He reported
that he could cope with life challenges including the loss of the girl in his life through prayer, his
training schedule, self- affirmation and being busy with his studies. He had learnt to let her go.

Sign: Faith Gichovi Date: 18th June, 2016

Faith M. Gichovi
Student psychologist
United States International University- Africa Clinical Supervisor: Dr. Mitchel Karume
United States Internationa