Case Report 3 – Intervention (or Assessment) case report
(e.g.)
The assessment and treatment of pathological grief in a 39-year-old woman
(or)
Neuropsychological assessment following brain injury in a 63-year-old male
This case report is submitted in partial fulfillment of the requirements for PSYC??? in the Master
of Psychology (Clinical) program at the University of New England. The material presented in
this case report is based on work undertaken by the Provisional Psychologist during a placement
at XXXX YYYY during the period MONTH – MONTH 20XX. No information that could
potentially lead to identification of the client has been included in the report.
Provisional Psychologist’s Name:
Supervisor’s (if you only have one) Name:
Title: E.g., Provisional Psychologist
Title: Clinical Psychologist
Signature: ____________________
Signature: ____________________
Date: ____________________
Date: ____________________
*Need to add the same information again if you had a secondary supervisor (e.g., a Psychologist
as your primary supervisor and a Clinical Psychologist from UNE as your secondary supervisor)
Report passed  Yes
 No
Unit Coordinator Name:
Title: e.g., Clinical Psychologist/Senior Lecturer
Signature: ____________________
Date: ____________________