Use it to organise an intake interview and write it up. Take only what you need for the assessment, and follow your placement's own form where it has one. Print with your browser's Print command; the site's menus are left off the paper.

Case history

Trainee: ____________________ Placement: ____________________ Date: ____________

Identifying details

Initials only, age, gender
Education and occupation
Who referred, and why now
Setting (outpatient, inpatient, school, community)

Presenting problems

In the client's own words
Onset, duration and course
What makes it better or worse
Effect on work, study, relationships and self-care

History of the present difficulty

First signs and what was happening then
Help sought so far and how it went
Medication, if any, and who prescribes it

Past history

Earlier episodes of mental ill health
Physical health and current conditions
Admissions, treatments and assessments

Family history

Family structure and who lives at home
Mental or physical illness in the family
Relationships and significant events

Personal history

Birth and early development, as far as known
Schooling and learning
Work history
Relationships and marriage
Religion and culture, as the client describes them

Substance use

Tobacco, naswar, alcohol, cannabis, other drugs
Prescribed medicines used other than prescribed

Personality before the difficulty

How the client, and people close to them, describe them before it began

Risk

Thoughts of self-harm or suicide, now and before
Risk to or from others
What was done about any risk, and who was told

Behaviour during the interview

Appearance, rapport, cooperation, attention
Anything that affected the interview (language, interpreter, family present)

Summary and plan

Main difficulties in two or three sentences
Assessments to give
Discussed with supervisor on (date)

Trainee: ______________________________ Date: ______________

Supervisor: ______________________________ Date: ______________

Template from PsychologyOrbit (https://psychologyorbit.com/templates/case-history). Free to print and adapt. No client names, phone numbers, CNIC or hospital numbers, or dates of birth.