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Intervention Report Writing

An intervention report (also known as therapy report, progress report, or case summary) is typically provided at the end of therapy with a client, or when the client is being handed over to another psychologist. It gives an overview of the client’s presenting problems and what was done in therapy to help the client address those issues. A basic intervention report should include the following details:

  1. Referral information – source of referral, referral reason;

  2. Background - assessment findings/diagnoses (which may or may not be done by the treating psychologist), history of intervention (if any);

  3. Presenting issues (if different from assessment findings/ new information is available to treating psychologist/ significant gap between the time of assessment and treatment);

  4. Therapy goals;

  5. Therapy progress - therapy modality, number of sessions, client’s progress, treatment obstacles, clinical impressions;

  6. Evaluation of treatment;

  7. Closure reason – satisfactory progress/ unsatisfactory progress/ prematurely terminated;

  8. Recommendations for follow-up or other support services.

 

Pelling, N. J. & Burton, L. J. (ed) (2018). The elements of Psychological case report writing in Australia. Routledge

This book provides in-depth case studies on a variety of clinical conditions such as anxiety disorders, PTSD, trichotillomania, grief and others. The case studies were written in the context of showcasing specific assessment and treatment competencies required for board certification in Australia. It explains the rationale for selecting a treatment approach, the specifics on how it was carried out, as well as the outcomes of treatment. Find out more here: https://www.routledge.com/The-Elements-of-Psychological-Case-Report-Writing-in-Australia/Pelling-Burton/p/book/9780815367185


A handy checklist which outlines the key indicators of a comprehensive intervention case report

Submission checklist for intervention case report – from Psychology Board of Australia


A useful summary of the broad domains and content required in a standard intervention case report. 

http://www.clinpsydhandbook.psych-sci.manchester.ac.uk/?page_id=289


A blog excerpt by marriage and family therapist, Dr Ili Walter, which provides a succinct and helpful template for organising case information in an intervention report. 

Case summary template (click to access)