Provides users a guideline into creating Consultation report based on the given scenario as well as providing the ideal layout of a consultation report.
Date: 30 October 2022
Client: Ms Lerato Masombuka
Consultant: Student Number (Clinical Psychologist)
Lerato (Ms Masombuka) was referred by her mother who was concerned about her daughters recent
unhealthy eating habits that is affecting her functioning.
The consultation was conducted with the aim of performing a clinical interview, assess the severity of the
symptoms, arrive at a diagnosis and to discuss the diagnosis with Lerato. Further relevant information was
gathered with the aim of developing a treatment and support intervention programme to assist Lerato and
her family in the management of her condition.
The consultation was conducted as a face-to-face interview between Lerato and myself. The 60-minute
interview was conducted in the interview room of the psychiatric outpatient ward. The consultation
occurred two days after the diagnosis of Bulimia Nervosa (BN) was made.
Description of the client:
At the consultation, Lerato an 18-year old black female, was well dressed and was verbally and
behaviourally well presented. Lerato had swollen cheeks, seemed tired and somewhat shy and appeared to
thinking a lot and worried.
Observations of the client:
My observations of Lerato’s situation are based on information obtained from Lerato’s family doctor, th
feedback from the SCOFF interview with Lerato and her mother.
The information provided by Lerato during the interview confirmed the presenting problem which centred
on the following:
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