I developed the following clinical writing sample for a doctorate program application and it is loosely based on a former client of mine. This document shows that I took initiative to seek out a template for this type of writing before we had even gotten into case conceptualize in courses. This, along with my desire to continue my education in the field, demonstrates that I am committed to life-long learning.
Clinical Writing Sample: Intake Summary
Presenting Concerns The client reports recently completing inpatient treatment for Anorexia Nervosa, binging/purging type. Additionally, the client reports frequent anxious thoughts, counting, and repetitive actions. The client is currently on a break from college, as her eating disorder caused a lack of energy and concentration which would be necessary for her to continue.
History of Presenting Concerns Client reports restricting calories as far back as her memory goes, around age 5. She reports previously using exercise as a way to compensate for caloric intake. Client recalls that her first instance of intentional vomiting occurred twelve months ago. At that time, the client reports she lost around fifteen pounds within a few weeks. In addition to AN, client says she was previously diagnosed with Generalized Anxiety Disorder and Post-Traumatic Stress Disorder in her childhood. During inpatient treatment for AN, the client gained around fifteen pounds and began to follow a meal plan based on exchanges. Client reports no purging within the last 75 days.
Medical History The client is medically stable as verified by her physician at the inpatient facility from which she was recently discharged.
Personal & Family Information Client reports being born into a household with a single mother who was diagnosed with Schizophrenia and Bipolar Disorder. She spent much of her childhood living with her grandmother and has never had any contact with her father. Her mother has a long history of frequent hospitalizations due to suicide attempts. Client recalls that she would restrict calorie intake as a child because she believed if she starved, her mother would be released from the hospital. Client was living with close friends near her college campus before being admitted to the inpatient facility. She is currently staying with her aunt, as she feels that is the best support for her while she is in acute recovery from AN. The client reports no drug use, besides occasional social drinking. Client intends to pursue a master’s degree within the next year.
Clinical Impressions & Observations The client has a robust trauma history, along with GAD and AN. Additionally, the client appears to be struggling with Obsessive Compulsive Disorder as she compulsively counts items feels her day is interrupted if she is not able to do so. Although the client had difficulty making eye contact and appeared restless, she presented as intelligent, self-aware, and motivated to get better. Treatment Recommendations At this time, it is recommended that the client participate in our Intensive Outpatient Program with group programming 9 hours per week. Three of these hours will be supported dining. In addition to IOP, the client will meet weekly with an individual counselor and a nutritionist. Her RD will help her maintain weight through a comprehensive meal plan and her individual counselor will help the client process trauma, develop coping skills, and identify personal goals. Goals for individual psychotherapy include: reducing instances of counting by utilizing distress tolerance skills; completing psychoeducation on trauma, anxiety, eating disorders through recommended reading; decrease distressing body image concerns through mirror work; process trauma through EMDR sessions.