Preliminary Report
Department of Clinical Psychology
School of Professional Psychology
University of Management and Technology
We train professionals
Preliminary Report I
Identifying Data
Client’s Initials: A. S
Age: 28 years
Gender: Female
Education: M.A
No. of Siblings: 6
Birth Order: 2nd born
Marital Status: single
Institution: F.H
Total number of sessions: 3
Initial date seen: 16-03-2023
Last date seen:
Source and Reason for Referral
The client was referred by the clinical psychologist for the assessment and management
of the following presenting complaints as mentioned in Table 1.
Presenting Problems
Table 1
Duration and Presenting Complaints Based upon the Clinical Interview Taken from the Client
Duration Presenting Complaints
10 سال سے ہوتی ہےTension
3 سال سے پٹھوں میں کچھاؤ محسوس ہوتا ہے
3 سال سے ریڑھ کی ہڈی درد کرتی ہے
3 سال سے سرمیں درد ہوتی ہے
1 سال سے چکر آتے ھیں
Initial Information
The client A.S was a 28-year-old female with average hight and weight. She was
observed through participant observation during the initial session. The session was taken in the
ward of the institute. The client was dressed in the traditional casual Pakistani attire shalwar
kameez and jersi along with dupata. Her dress was weather and culturally appropriate. She wore
neat and clean dress and slippers. Her gait was not normal as he was walking in childish manner.
She was noted to have appropriate grooming, i.e. her dress was clean but not ironed, her hands
and feet were clean. Her sitting posture was comfortable, but her shoulders were bended. The
client had a generally worried facial expression and continuously twisting her fingers. Her hair
was not combed. She maintained eye-contact to the trainee throughout the session. She was
noted to be leaning towards the trainee clinical psychologist throughout the session. She paid
adequate attention to the trainee and answered every question properly. But her speech was not
clear, and her tone of voice was fluctuating due to crying. It was noticed that her speech was
disorganized as she was shifting from one point to another. The client gave few brief and few
detailed answers to the trainee, hence the trainee had to probe a lot to get the information. During
the interview, she seemed sad and disturbed. She was worried about her parents and health issues
after that she started to cry and started to talk about his sisters that she had very good bond with
them. At the end of the session client went out for her review with doctor.
Initial Assessment
Assessment modalities included.
● Behavioral Observation (Haynes,2014) It was done to access behaviour of the client during the
initial assessment phase, or the question asked during CI. The client activity level, distractibility
and other psychological impairments can also be accessed.
● Clinical interview (Allen & Becker,2019) Semi structured Clinical Interview was done to gain
in-depth information of the client’s demographic, psychiatric history and current problems. It
will help to diagnose and develop a treatment plan for the client.
● Mental Sates Examination (Hufton et al.,2022) It will be used for the structured assessment of
the client’s behavioral and level of cognitive functioning including alertness, language, memory,
orientation, constructional ability and abstract reasoning. It will be used to know the current
mental status of the client.
● Subjective Rating (Vallade,2019) It will be taken by the client for the purpose of understanding
and to check the frequency, intensity and duration of client problems. It will be measured on a
Likert scale.
● DSM Checklist of Schizophrenia will be used to assess the problem and diagnosis of presenting
complaints.
Preliminary Findings
Provisional Formulation
Based on behavioral observation and detailed clinical interview with the client, it
can be hypothesized that the client’s family history of psychological issues in mother, unhealthy
relationship with siblings, adjustment in new house and her health condition predisposed her to
developing the current symptoms. Her precipitating factors might be stressful life events, illness
of her father and mother and aggressive behavior of father. Her maintain factors might be her
health issues and unsupportive home environment. His protective factors included having good
insight of the problem, willingness to get treatment, good medication adherence and good
rapport with the trainee. It can be hypothesized that the client was showing symptoms of
generalized anxiety disorder.
Future Plans
Assessment
Baseline charts of presenting complaints
Mental Status Examination (MSE)
Positive and Negative Syndrome Scale (PANSS)
Behavioral Checklist
Management
● Rapport Building will be done by establishing a therapeutic relationship and, ensure
confidentiality and to provide unconditional positive regard. This will be done to encourage the
client to open and as a reassurance.
● Supportive work is therapeutic relationship in which the therapist and the client share common
goals about the betterment of the client. The therapist has also some responsibility including
active listening, empathizing behaviour towards the client. This will encourage him to more
consult towards the therapist.
● Psychoeducation will be done to provide him awareness regarding the nature of her problem in
detail along with the reasons of issues that the client is facing.
● Relaxation exercise will be taught in order to help him feel comfortable and relax.
● To manage worrisome thoughts – The goal was set to mitigate her repetitive worries about future
and present through cognitive restructuring.
