Counselling reports present a client to interested readers in a way that improves understanding, summarises facts in a logical order, and assists in generating treatment plans or actions appropriate to the individual. A professional counselling report should demonstrate knowledge of principles of human behaviour and methods for diagnosis and treatment of behavioural or emotional disorders. Construct reports using observations, data and historical information in a logically ordered presentation.
Collect notes, background information and data collected during interviews and evaluations. Place on worktable for easy reference when writing the clinical report.
Create a report outline that covers the reason for referral, background information, clinical observations, your interactions with the client, conclusions and recommendations.
Review background information and summarise key elements that contribute to a complete description of the client's status and support your diagnosis and treatment recommendations. Include information provided by others, including medical, educational, and work-related data and observations of physicians, parents, teachers and family members, if available. Place information in appropriate report section.
Write up your clinical observations of the client's behaviour throughout the intake process and interactions during counselling. Report any testing or formal clinical assessment data, along with a brief description of the instrument used, what it measured, and the client's reactions during testing.
Pull together the analysis of background information, observations, and test interpretation data into a supportable conclusion about the client's status, skills, problems, resources and needs.
Construct a recommended treatment plan or list of future actions tied to the reason for referral and your conclusions.
Review the draft written counselling report with consideration of the clinical knowledge and reading level of those receiving the report. Check the report for spelling and grammar correctness. Remove unnecessary technical jargon. Complete edit.
Place client information such as name, birth date, name of the counsellor and date(s) of counselling session(s) at the top of the first page. Place the client's name and page number on all subsequent pages. Identify the information as confidential on each page.
Sign the report with your name, academic degree and license or certification information.
- "The Child Clinician's Report Writing Handbook"; Ellen Bratton; 2007
- Massachusetts Department of Mental Health: Report Writing Guidelines