This section is sometimes labelled as PURPOSE FOR EVALUATION or REASON FOR
REFERRAL. Usually, a person comes in with a reason for the assessment. This sets the tone of
the report. This section aims to introduce the client and current situation that led him/her to seek
the current assessment. Simply and briefly describe this information. This is the section you will
want to be able to come back to when you have interpreted test data.

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After getting a sufficient idea of the reason for referral, the next step is to describe the
history and background of the client. Before that, be reminded by the general pointers that follow
in doing so.

General pointers in writing your report

Recall what we’ve discussed about writing a social case history/report. This section talks
about your client’s background. This will sound more like a narrative or story than a Q&A or a
rundown of your client’s responses to your interview questions. As such, we do not want to see
an interview transcript in this section. It is possible that some responses in the interview are not
necessary or relevant and therefore not included in this section. So, select the information you
think will provide us a better understanding of who your client is.

You may choose to organize this section in several ways: chronologically or
developmentally, or according to milestones or important events in your client’s life. This is up
to you. Just be sure that the information you provide gives us a biographical sketch; that it is
comprehensive, cohesive, and concise.

With regard to the voice and tone of this section: please describe this section from a third
person perspective, as it is a formal report. Observations during your interviews need not to be
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Strictly Confidential Report for: X
written here. Behavioral observations are part of another section. Focus on the client’s
background. Be careful of the words you use to describe your client: they must be neutral and not
evaluative. Avoid making analyses of your client’s behavior here. Save your analysis for the
analysis section.

Finally, be specific, and concrete (as opposed to being vague), when describing your
client. For example, avoid writing “She tends to feel anxious in various situations”—tell us how
this anxiety manifests and during which kinds of situations.

In terms of content, let the following guide you in writing your client’s case history.


Number of children, and position of the client are the primary information in this section.
Socio-economic status, now and before are also considerations. Other factors like presence of
members of the extended family, or changes of domicile may also be important to explore.

Although not recommended to be directly placed on this section, the use of the genogram
in the interview may be a very helpful tool to identify the different members of the family.
Present living conditions, living units, occupations, and ages of the different members of the
family may initially be obtained using this method.

Other relevant characteristics about the family should also be included in this section.
Keep in mind that there is a tendency for most people to describe their family in an overly
positive way. It may be important to uncover the real family situation, and the defects in its
functioning, at least to a certain extent.

Some important aspects to look into:
 Description of parents’ personalities: Main traits, positive and negative (About their weak
points, one may ask something like, “Anything you would have liked to be different in your
father? In your mother?”)
 Relationship between parents and conflicts: Any difficulty between both parents? What
was the cause of their arguments or quarrels? Was there any physical violence between
them? How were problems solved? Who was making decisions?
 Communication: With whom was it possible to speak more easily? With whom did you
speak of personal matters? Any conflicts?
 Affection: which parent was more affectionate, or more demonstrative of his/her affection?
What were the signs of affection shown?
 Basic values stressed by parents: Education? Money? Honesty? Responsibility? How
were rules enforced, and values transmitted? Any punishments? How were they
administered? How frequently? By whom? What was your reaction to such punishment
(was it deserved or unfair)?
 Atmosphere at home: family reunions, vacations together, etc.
 Siblings: Who were closest to each other? Anything significant about them? Who was the
mother’s/father’s favorite?

Strictly Confidential Report for: X
 Pathology in the family: Is there a history of mental illness in the family? Who? How
serious? What other illnesses are present?
 Significant events in the life of the family: Financial crisis, separation of parents,
remarriage, etc.

Personal background

This is aimed at discovering the significant events that have marked the life of the person,
starting from childhood until now. It also includes the personality of the patient.

Some of the important points are:
 Earliest memory: What was it? How old were you? Pleasant or unpleasant? Any early
traumatic memory? General feeling about those early years?
 School: First memories of school? Relations with peers, at different stages (elementary,
high school, college)? Academic performance? Favorite subjects? Disliked subjects?
Interest of parents toward school life? Extracurricular activities?
 Health: Any illness? At what age? Sleep pattern?
 Friendships: Social life, number of friends, depth of communication, etc.
 Habits: drinking, smoking, drugs?
 Hobbies and special interests: Use of free time? What readings? Favorite book or movie?
 Dreams: Any memory of dreams? Any recurrent theme? Any nightmare or strange dream?
 Emotions: Go through some main emotions (sadness, loneliness, anger) and ask if these are
experienced, how often, how intensely, and how they are handled.
 Self-concept: Traits that one likes or dislikes about oneself? What was the self-image when
young (shy, active, happy)? What do friends say about you? What comments have been
made by parents, teachers and siblings?
 Religion: What religion? How important? Image of God? Prayer, what kind?
 Work: Experience of work? Why choice of present profession (or course of study)?
 Future: What fantasies about the future, let’s say ten years from now?
 Wishes: What are your three main wishes?
 Relationships and emotional connectedness to others, including romantic relationships



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