Content Writing

From the Reason for Consultation to the History

Unlike the clinical history that records both the apparent and the real reason, the psychological report is written exclusively on the real reason for consultation.

This is the underlying problem identified by the professional after the evaluation, beyond the patient's initial complaint.

Next, in the "General Case Information" or "General Description" section, the mental examination, personal and family history (medical, psychiatric, legal) and the current situation that generates the discomfort are written, maintaining coherence with the reason for consultation.

Instruments and Exploration Areas

When listing the tests applied, the full name of the test, the date of application and the correction manual used (for example, specify whether Koppitz or Machover was used for the Human Figure).

This is vital because the tests have a limited shelf life (approximately six months) and the results may vary according to the author of the correction manual.

After listing the instruments, a summary of the quantitative and qualitative results is made.

Then, the areas of exploration are described; in children they are detailed separately (social, cognitive, emotional, etc.), while in adults they are usually integrated in paragraphs covering academic, occupational, emotional and social spheres.

Summary

In the report, only the real reason for consultation determined by the professional is recorded, omitting the apparent initial complaint, and it is integrated with the history and the mental examination.

It is vital to detail the instruments applied indicating full name, date and correction manual used, since the results may vary according to the author and have a limited temporal validity.

The results are presented summarizing the quantitative and qualitative findings, describing the areas of exploration separately in children or integrated in academic, labor and social spheres in the case of adults.