Qualifications Office
Qualification in Clinical Neuropsychology
Useful Forms and Case Log Book Examples
From 1 February 2013
Qualifications Office
The British Psychological Society,
St Andrews House,
48 Princess Road East,
Leicester, LE1 7DR.
Tel: (0116) 252 9505
Fax: (0116) 227 1314
Email: exams@bps.org.uk
http://www.bps.org.uk/qualifications
Contents
Page
Checklist for enrolment
Enrolment Form
Request for Approval of Supervisor
Plan of Training
Supervision Plan
Application for Exemption Form
Supervision Log
Clinical Log Book Summary Sheet
Case Log Book Example – blank
Case Log Book Example 1 – Adult
Case Log Book Example 2 – Adult
Case Log Book Example 3 – Paediatric
Case Log Book Example 4 – Paediatric
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5
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10
12
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25
Important Note
Candidates are reminded that they should make every effort to ensure that all
documentation including their supervision plan is word processed and accurate. The
most common source of delays in processing applications to enrol for the
Qualification in Clinical Neuropsychology arise as a result of forms which are
incomplete or contain inadequate information.
3
CLINICAL NEUROPSYCHOLOGY QUALIFICATIONS
BOARD
Checklist for Enrolment
The first stage in enrolling on the Qualification in Clinical Neuropsychology is to identify a clinical
supervisor who is a Full Member of the DoN and who appears on the Society’s Specialist Register of
Clinical Neuropsychologists.
The next stage is to send the following to the Society’s Leicester Office:

Enrolment form

Plan of Training form

Supervision Plan

Request for approval of supervisor form (if your supervisor has not previously been approved
as a clinical supervisor for the QiCN)

A copy of the contract(s) agreed and signed by you and your supervisor(s) (for all supervisors
named on your supervision plan)

Enrolment fee (or invoice details)

Backdating fee (if applicable)

Equal opportunities monitoring form

Copy of a current certificate from either the Criminal Records Bureau, Disclosure Scotland or
Access Northern Ireland (dated in the last 2 years or from your current post)

Application for exemption form and supporting evidence if you are applying for any
exemptions
If any of this information is missing your application will not be processed. Please read the Candidate
Handbook and the Regulations for the Society’s Postgraduate Qualifications and discuss your
application with your supervisor(s) before submitting it to the Society.
4
Enrolment Form for the Qualification in Clinical Neuropsychology (continued)
Title:
Mr/ Mrs/ Ms/ Dr
Surname:
Forename(s):
Date of birth:
Email:
Daytime telephone number:
Society membership number:
HCPC registration number:
To be eligible to enrol for the QiCN (adult) you must have all of the following:
Graduate Basis for Chartered Membership
Yes/No
Eligibility for Full Membership of the Division of Clinical Psychology
Yes/No
Registration with the HCPC as a Clinical Psychologist
Yes/No
To be eligible to enrol for the QiCN (paediatric) you must have all of the following:
Graduate Basis for Chartered Membership
Yes/No
Eligibility for Full Membership of the Division of Clinical Psychology or Division of Educational and
Child Psychology
Yes/No
Registration with the HCPC as a Clinical Psychologist or an Educational Psychologist
Yes/No
Do you wish to apply for exemption from any part?
Part 1: Underpinning knowledge
Yes/No
Part 2: Research Portfolio
Yes/No
Part 3: Portfolio of Clinical Competence
Yes/No
If you wish to apply for any exemptions, complete and return the Application for Exemption Form with
this enrolment form
Please give details of your proposed (Principal) Clinical Supervisor:
Name .....................................................................................................................................................
Membership No ....................................... HCPC registration number...................................................
Please give details of your proposed Research Supervisor unless applying for an exemption:
Name .....................................................................................................................................................
Membership No ....................................... HCPC registration number...................................................
5
Enrolment Form for the Qualification in Clinical Neuropsychology (continued)
Previous enrolment for a Society-accredited training programme
Have you previously been enrolled for a Society-accredited training programme and left prior to
completion? Yes/No
If yes, please state why you left the programme:
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
Enrolment fee (and backdating fee, if applicable) can be made by the following methods:
- Cheque made payable to The British Psychological Society;
- Credit/ Debit Card (details to be provided via telephone)
- Invoiced to employer.
If invoice requested please give name and address details and, if applicable, the purchase order
number:
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
Disability Discrimination Act
If you have a disability or special requirements you may need the Society to make reasonable
adjustments to, or provide special facilities for, your examination. If this is the case please advise us
here.
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
We will contact you to discuss your requirements and to ensure that adequate arrangements are
made.
6
References
The Qualifications Board will need to seek references in relation to the information you have provided.
Please provide below the names of two people who the assessors can contact in relation to your
training and practice in clinical neuropsychology. One reference must relate to your academic
studies, and the other reference must relate to your practice. At least one name must appear on the
Society’s Register of Chartered Psychologists and the psychology section of the Health Professions
Council’s Register. Your Co-ordinating Supervisor (as named on your supervision plan) cannot
normally be named as referee, nor can a fellow candidate.
Name
Professional accreditation/ registration
and membership number
e.g. HCPC registration number, BPS
membership number
Address
In what capacity do you know this
person
e.g. Supervisor, tutor, line manager,
colleague
Name
Professional accreditation/ registration
and membership number
e.g. HCPC registration number, BPS
membership number
Address
In what capacity do you know this
person
e.g. Supervisor, tutor, line manager,
colleague
7
Candidate’s Declaration
I wish to be enrolled on the British Psychological Society Qualification in Clinical Neuropsychology, and
confirm that I have read the current Candidate Handbook for the Qualification in Clinical
Neuropsychology and that I will maintain an updated knowledge of the Candidate Handbook. I certify
that I have the Graduate Basis for Chartered Membership with the British Psychological Society and
am currently registered with the Health and Care Professions Council as a Clinical
Psychologist/Educational Psychologist (delete as appropriate) and that the facts stated on this form
are correct:
Signature of Candidate:
Date:
Agreement of Co-ordinating Supervisor
I confirm that I have reviewed this application and discussed it with the above named applicant. I
confirm my agreement to act as Co-ordinating Supervisor for this applicant. I am a full member of the
Division of Neuropsychology and am named on the Society’s Specialist Register of Clinical
Neuropsychologists. I am entered on the Register of Applied Psychology Practice Supervisors, or am
willing to undertake training to meet this requirement. I agree to be responsible to the Clinical
Neuropsychology Qualifications Board for the items listed in the Candidate Handbook for the
Qualification in Clinical Neuropsychology as the responsibilities of the supervisor. I will undertake
training for the role of QiCN supervisor within 12 months of approval if required.
Signature of
Coordinating Supervisor:
Date:
This form should be returned to:
Qualifications Office
The British Psychological Society
St Andrews House
48 Princess Road East
Leicester LE1 7DR
By providing the personal information in the application form you are agreeing to the Society processing and holding it only for
the purposes stated in our Data Protection Act registration. For further information about these purposes and the Act itself
please visit the privacy\DPA policy hyperlink at the foot of the Society’s website home page at www.bps.org.uk
8
CLINICAL NEUROPSYCHOLOGY QUALIFICATIONS
BOARD
Request for Approval of Proposed Supervisor for the Qualification in
Clinical Neuropsychology
Proposed supervisor’s name: ........................................... ……………………………………………………
Proposed supervisor’s membership number: ............................................. …………………………………
Proposed supervisor’s HCPC registration number: .................................... …………………………………
Proposed supervisor’s phone: .......................................... ……………………………………………………
Proposed supervisor’s e-mail: ........................................... ……………………………………………………
Is the proposed supervisor
a Full Member of the Division of Neuropsychology and entered on the Specialist Register of Clinical
Neuropsychologists: ....................................................................................................................... Yes/No
Name of Candidate who proposes to be supervised: ..............................................................................
Candidate’s membership number: ............................................................................................................
Candidate’s HCPC registration number: ....................................................................................................
Date when supervision plan naming proposed supervisor was / will be submitted: ................................
...................................................................................................................................................................
Please attach a brief CV regarding the proposed supervisor. This must include details of their current
post.
Newly approved supervisors for the QiCN will need to undertake training for the role normally within
12 months of being approved in the role.
Proposed supervisor’s signature: .........................................................................................................
Date: ......................................................................................................................................................
Candidate’s signature: ..........................................................................................................................
Date: ......................................................................................................................................................
Return this form to:
The Qualifications Officer for the QiCN
The British Psychological Society
St Andrews House
48 Princess Road East
Leicester, LE1 7DR
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CLINICAL NEUROPSYCHOLOGY QUALIFICATIONS
BOARD
Plan of Training for the Qualification in Clinical Neuropsychology
1. Candidates Details:
Name: ..............................................................................................................................................
Membership number: ..........................................................................................................................
HCPC registration number: .................................................................................................................
Telephone Number: ............................................................................................................................
Email: .................................................................................................................................................
2. Planning to undertake (Tick one):
Adult QiCN
Paediatric QiCN
3. Date gained registration with the HCPC as a Clinical Psychologist: ........................................
Date gained eligibility for Full Membership of the Division of Clinical Psychology: ..............
(or for some candidates for Paediatric QiCN),
Date gained registration with the HCPC as an Educational Psychologist: ..............................
Date gained eligibility for Full Membership of the Division of Educational and Child
Psychology:.....................................................................................................................................
4. Method by which you plan to complete the Knowledge Dimension (Part 1):
by completing a Society accredited university course at
……………………………………………… (name of university)
by taking the examinations and essays set by the Clinical Neuropsychology
Qualifications Board
by applying for exemption on the basis of a Society-accredited course already completed
at ………………………………….. (name of university)
(complete separate Exemption Form).
5. Method by which you plan to complete the Research Dimension
(Part 2):
by completing the research component of a Society accredited MSc course in clinical
neuropsychology at ………………………….…………(name of university)
by undertaking a piece of research and submitting a research portfolio for
assessment by the Clinical Neuropsychology Qualifications Board
by applying for exemption on the basis of a research project that was examined
as part of a post-graduate qualification or published in a peer-reviewed journal
(complete separate Exemption Form)
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6. Method by which you plan to complete the Practice Dimension (Part 3):
by completion of 2 years full-time clinical neuropsychology practice
by completion of part-time clinical neuropsychology practice, working
……………of whole-time, so taking …………. months to achieve equivalent
of 24 months full-time.
With supervision from: ……………………………………………….. (name)
and ………………………………………………….(name)
(if another supervisor will contribute).
(Also complete a separate Clinical Supervision Plan.)
Candidate’s signature: .......................................................................................................................
Date: .....................................................................................................................................................
Co-ordinating Supervisor’s signature: .............................................................................................
Date: .....................................................................................................................................................
Return this form to:
The Qualifications Officer for the QiCN
The British Psychological Society
St Andrews House
48 Princess Road East
Leicester, LE1 7DR
11
CLINICAL NEUROPSYCHOLOGY QUALIFICATIONS
BOARD
Supervision Plan for the Qualification in Clinical
Neuropsychology
Guidance notes for completion of the supervision plan

If you are requesting backdating of clinical practice, you must ensure that the
supervision arrangements outlined in your supervision plan cover both the proposed
backdated period and the forward period of practice. This includes the names of
your supervisors and frequency and duration of supervision.

If you are requesting backdating of clinical practice, the proposed start date of your
supervision plan will be retrospective. You must make clear the period which you
want to be backdated. The maximum period of backdating that can be granted is 12
months (or part time equivalent).

You must ensure that you have clearly indicated that you have plans in place to
accrue a minimum of 60 hours of supervision during the course of your supervision
plan. Please check that the frequency and duration of supervision which you
stipulate in your plan amount to the required 60 hours. If they do not amount to at
least 60 hours, please do not submit your application to enrol until you have concrete
plans for some additional supervision. This is one of the most common reason for
delays in processing an enrolment application.

Candidates are reminded that they should make every effort to ensure that all
documentation including their supervision plan is word processed and accurate.
Alterations/additions will only be considered in exceptional circumstances after a
written submission to the Qualifications Officer has been discussed with the Registrar
and Chief Supervisor.
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Supervision Plan for the Qualification in Clinical Neuropsychology
1. Candidate's details
Candidate’s name: .................................................................................................................
BPS Membership No:............................ HCPC registration number: ......................................
Telephone Number (work):.......................................... Fax:....................................................
Email: ....................................................................................................................................
Details of current employing organisation:..............................................................................
..............................................................................................................................................
..............................................................................................................................................
2. Proposed Co-ordinating Supervisor's details
Name of proposed Co-ordinating Supervisor: ........................................................................
BPS Membership No:............................ HCPC registration number: ......................................
Position held: .........................................................................................................................
Email: ....................................................................................................................................
Is this supervisor located within the candidate’s service? .......................................................
Please give a brief description of this supervisor's current employing organisation and
responsibilities.
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
Is this supervisor a Full Member of the Division of Neuropsychology and entered on the
Society’s Specialist Register of Clinical Neuropsychologists?
Yes/No
Has this supervisor already been approved by the Clinical Neuropsychology Qualifications
Board?
Yes/No
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3. Supervision Plan
Date when supervised clinical practice is expected to start ...................................................
Date when supervised clinical practice is expected to be completed .....................................
If you are applying for backdating by putting a retrospective start date above, please confirm
that you have been keeping a case log and supervision log for the backdating period (please
do not submit these, but retain them and insert them into your portfolio for assessment at the
appropriate point):
..............................................................................................................................................
..............................................................................................................................................
Will the proposed Co-ordinating Supervisor be able to provide supervision for the full range
of clinical work needed for the clinical portfolio (to include acquired and non-acquired brain
injury, degenerative conditions, psychosomatic disorder, a range of disability and a range or
reasons for referral)?
Yes/No
Will an additional supervisor provide some of the supervision?
Yes/No
If ‘Yes’, please give details of the additional supervisor:
Name of proposed additional supervisor: ...............................................................................
BPS Membership No:............................ HCPC registration number: ......................................
Position held: .........................................................................................................................
Email: ....................................................................................................................................
Is this supervisor located within the candidate’s service? .......................................................
Please give a brief description of this supervisor's current employing organisation and
responsibilities.
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
Areas of work for which additional supervisor will provide supervision:
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
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Outline the way in which supervision will be provided, giving details of where, when and how
supervision will take place, and the nature and extent of supervision which will be provided.
The frequency and duration of supervision stated below must ensure that 60 hours of
supervision will be achieved in total. If you are receiving any group supervision, the
supervisor leading this group needs to be named on this supervision plan. Supervision
hours received as part of a group are calculated proportionately so please ensure that you
take this into account when calculating your supervision hours.
For the Co-ordinating Supervisor
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
For additional supervisor
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
Signature of candidate: ..........................................................................................................
Date: ......................................................................................................................................
Signature of Co-ordinating Supervisor: ..................................................................................
Date: ......................................................................................................................................
Signature of additional supervisor: .........................................................................................
Date: ......................................................................................................................................
To be completed by the Chief Supervisor for Qualifications Board
Comments
..............................................................................................................................................
..............................................................................................................................................
Date of ratification .................................. Expected date of completion ..................................
Signature ...............................................................................................................................
15
CLINICAL NEUROPSYCHOLOGY QUALIFICATIONS
BOARD
Application for Exemption Form
Candidates for the Qualification in Clinical Neuropsychology may apply for exemption from one or
more parts of the qualification. Please attach extra sheets if necessary. N.B. Applications for
exemption can only be submitted at the same time as, or after, a candidate has applied to enrol
on the QiCN.
Please complete the relevant section of this form for each part from which you wish to apply for an
exemption
Candidate name ....................................................................................................................................
Membership Number .............................................................................................................................
HCPC Registration number...................................................................................................................
Telephone Number ...............................................................................................................................
Email .....................................................................................................................................................
I am applying for exemption from part(s) of the adult route
Yes/No
I am applying for exemption from part(s) of the paediatric route
Yes/No
PART 1: Knowledge Dimension
A qualification in Clinical Neuropsychology or Paediatric Clinical Neuropsychology which is accredited
by the Society on the recommendation of the Committee on Training in Clinical Neuropsychology will
give exemption from the examination of underpinning knowledge.
Do you wish to apply for exemption from Part 1? YES/NO
Please enclose the original of either the certificate or letter of successful completion as evidence. This
will be returned promptly by recorded delivery.
N.B If you are in the process of completing an accredited course in fulfilment of the knowledge
dimension, please do not indicate “yes” above; please indicate on your plan of training that you are
completing an accredited course and apply for exemption when you have received either the certificate
or letter of successful completion.
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PART 2: Research Dimension
Research (carried out and) successfully completed as part of a Society-accredited course in clinical
neuropsychology or paediatric clinical neuropsychology will give exemption from the research portfolio
requirement
Or
Research in clinical or educational psychology as part of a postgraduate qualification
Or
Research published in good quality peer reviewed journals
Do you wish to apply for exemption from Part 2?
YES/NO
Please indicate the evidence that you are providing for this exemption:
1. Original certificate or letter of successful completion from a Society-accredited Masters degree in
Clinical Neuropsychology or Paediatric Clinical Neuropsychology;
YES/NO
2. An abstract of a piece of research completed as part of a postgraduate qualification in clinical or
educational psychology (e.g. DClinPsy, DEdPsy), along with the original degree certificate indicating
when and where the thesis was examined and the degree awarded.
YES/NO
If you are applying for exemption under option 3, please provide further details below:
a. Name of university where the postgraduate qualification (e.g. DClinPsy) was completed:
.............................................................................................................................................
b. Name of Qualification:
.............................................................................................................................................
c. Year awarded:
.............................................................................................................................................
I confirm that the enclosed abstract pertains to the above-named qualification:
Signature: ...................................................................................................................................................
Name: .........................................................................................................................................................
Date: ...........................................................................................................................................................
By providing the personal information in the application form you are agreeing to the Society processing and holding it only for
the purpose stated in our Data Protection Act registration. For further information about these purposes and the Act itself
please visit the privacy\DPA policy hyperlink at the foot of the Society’s website home page at www.bps.org.uk
17
Supervision Log
This document needs to log the supervision received during the course of your supervision plan. It will need to cover a minimum of 60 hours of supervision as per
the Candidate Handbook (February 2013). At least half of this supervision needs to be face-to-face and individual, and any group supervision needs to be
calculated proportionately. The supervision detailed below needs to be in line with the details approved in your supervision plan. Please duplicate this page if you
need to.
Candidate name: ..............................................................................................................................
Membership number: .......................................................................................................................
Date of
supervision
session
Duration
Method (e.g. individual,
group including the size of
the group, face-to-face,
telephone)
Supervisor’s name
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Candidate’s signature
Supervisor’s signature
Clinical Log Book Summary Sheet for Qualification in working with Adults or
Children and Adolescents
Case
No.
Sex
Age
Diagnosis
Assessment,
intervention
or both
Hours of contact with:
client/
child
family/
carers
other
prof.
Continue on a further sheet if needed
Indicate which profession contact with other prof. involved, using abbreviations such as
edn. = school/college staff,
s.w. - social work,
emp. = employer or employment service
Provide a key for all abbreviations used.
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Case Log Book Example - for qualifications in working with adults or children
There should be a series of sheets indicating clinical activity and signed by both
candidate and supervisor
Case number:Age:Seen as part of team? (Specify type of team)
Date(s) seen, or period seen over
Source of referral
Reason for referral
Sex:-
In/out/day patient?
Diagnosis/Diagnoses :
1
2
3
Type of neuropsychology involvement (e.g.,
screening assessment, assessment to aid
diagnosis, rehabilitation) - list all
Main neuropsychological/psychological
problem(s) identified.
Assessments used (list tests, brief summary of
any other types of assessment)
Clinical Activity
Face-to face contacts (number and total
time)
Contacts with family or carers/friends
(number, relationship and time)
Contacts with other professions (nature,
extent and time)
Other activity (nature and extent)
Outcome/outputs
The above record accurately reflects the candidate's work with this client.
Signed and dated ……………………………………………………….. (candidate)
Signed and dated ……………………………………………………….. (supervisor)
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Case Log Book Example 1- for Adult Qualification
Specimen completed in italics
There should be a series of sheets indicating clinical activity and signed by both candidate and
supervisor
Case number:- 01
Age:- 18
Seen as part of team? (Specify type of team)
Date(s) seen, or period seen over
Source of referral
Reason for referral
Sex:- M
In/out/day patient? I.p.
Yes - in-patient rehab. team
Mar 01 - Oct 01
Consultant in Rehab. Medicine
For assessment and intervention as part
of in-patient rehab
Traumatic Brain Injury
History of anxiety and school refusal
Diagnosis/Diagnoses :
1
2
3
Type of neuropsychology involvement (e.g.,
screening assessment, assessment to aid
diagnosis, rehabilitation) - list all
Main neuropsychological/psychological
problem(s) identified.
Assessment and intervention
Cognitive impairment - reduced speed of
processing, visual perceptual problems.
Behavioural problems - destructive and
impulsive
WAIS - III, RBMT, FAS, TMT, NART
behavioural assessment - ABC
Assessments used (list tests, brief summary of
any other types of assessment)
Clinical Activity
Face-to face contacts (number and total
time)
Contacts with family or carers/friends
(number, relationship and time)
25 sessions with client - total 20 hours
5 face-to face with parents - 5 hours
20 telephone contacts with parents - 5
hours
1 face-to face with college tutor - 1 hour
2 telephone contact with college - 1 hour
Collaboration with nursing staff on
behavioural intervention - 20 hours
Contacts with other professions (nature,
extent and time)
Other activity (nature and extent)
Discharged home to parents, with ongoing
community support
Outcome/outputs
The above record accurately reflects the candidate's work with this client.
Signed and dated ……………………………………………………….. (candidate)
Signed and dated ……………………………………………………….. (supervisor)
21
Case Log Book Example 2- for Adult Qualification
Specimen completed in italics
There should be a series of sheets indicating clinical activity and signed by both candidate and
supervisor
Sex:- F
In/out/day patient? Out-pt
no
4 & 14 December 2000, 5 July 2001
Consultant Neurologist
Attention/concentration problems
following recovery from meningitis
Past meningitis
Case number:-02
Age:-42
Seen as part of team? (Specify type of team)
Date(s) seen, or period seen over
Source of referral
Reason for referral
Diagnosis/Diagnoses :
1
2
3
Type of neuropsychology involvement (e.g.,
screening assessment, assessment to aid
diagnosis, rehabilitation) - list all
Main neuropsychological/psychological
problem(s) identified.
Assessment, advice, reassessment after 6
months
Impaired attention, specific visual
perceptual problems
AMIPB, VOSP, TEA
Assessments used (list tests, brief summary of
any other types of assessment)
Clinical Activity
Face-to face contacts (number and total
time)
Contacts with family or carers/friends
(number, relationship and time)
Contacts with other professions (nature,
extent and time)
Other activity (nature and extent)
3 - total 3 hours
none
none
Advice on return to work and driving
Subtle deficits identified, advice given,
patient returned to work
Outcome/outputs
The above record accurately reflects the candidate's work with this client.
Signed and dated ……………………………………………………….. (candidate)
Signed and dated ……………………………………………………….. (supervisor)
22
Clinical Log Book Example 3- for Paediatric Qualification
Specimen completed in italics
There should be a series of sheets indicating clinical activity and signed by both candidate and
supervisor
Case number:- 1
Age:- 8
Seen as part of team? (Specify type of team)
Date(s) seen, or period seen over
Source of referral
Reason for referral
Sex:- M
In/out/day patient? I & D
Diagnosis/Diagnoses :
Traumatic Brain Injury
Yes – in & day patient rehab. teams
Mar 01 –June 01
Consultant Paediatric Neurosurgeon
For assessment and intervention
1
2
3
Type of neuropsychology involvement (e.g.,
screening assessment, assessment to aid
diagnosis, rehabilitation) - list all
Psychometric assessment to delineate cognitive
profile and monitor progress, assessment of
behaviour, assessment of psychological state
of child and family. Intervention with child,
consultancy to hospital team members, local
education and health professionals and coworking with SALT, hospital teachers and Ed
Psych.
Cognitive impairment - reduced speed of
processing, language, reading and spelling
problems, poor verbal memory, fatigue. Low
mood, avoiding contact with peers, unable to
cope in classroom. Low mood and anxiety in
family members.
WISC - III, WORD, WOLD, CMS, FAS, TEACh, behavioural – ABC, clinical assessment of
mood & RIES & BDS
Main neuropsychological/psychological
problem(s) identified.
Assessments used (list tests, brief summary of
any other types of assessment)
Clinical Activity
Face-to face contacts (number and total
time)
Contacts with family or carers/friends
(number, relationship and time)
24 sessions with client - total 22 hours
12 face-to face with parents - 8 hrs.
5
telephone contacts with parents - 3 hrs. 3
face-to-face with siblings-4hrs
1 face-to face with class teacher and SENCO 1 hr; 3 telephone contacts with school- 1 ½ hrs.
2 face-to-face with Ed Psych-2 hrs 4 joint
sessions with hospital teachers-3 hrs; 3 joint
sessions with SALT 3 hrs & 2 face-to-face 1½
hrs.; 1 face-to face with hospital social workerI ½ hrs; 1telephone contact with local Clin
Psych- ¾ hr
Weekly ward review with Hospital team
Discharge Case Conference with hospital team
and local health & education services and
family. Initial and review meetings at local
school. Advice provided for statementing
procedure.
Discharged home to parents, with ongoing
community support and review Case Conference
Contacts with other professions (nature
and extent)
Other activity (nature and extent)
Outcome/outputs
23
arranged forAutumn.
The above record accurately reflects the candidate's work with this client.
Signed and dated ……………………………………………………….. (candidate)
Signed and dated ……………………………………………………….. (supervisor)
24
Clinical Log Book Example 4 - for Paediatric Qualification
Specimen completed in italics
There should be a series of sheets indicating clinical activity and signed by both candidate and
supervisor
Case number:- 2
Age:- 15
Seen as part of team? (Specify type of team)
Date(s) seen, or period seen over
Source of referral
Reason for referral
Sex:- F
In/out/day patient? O
No
Jan 01 –Nov01
GP
For assessment and advice
Diagnosis/Diagnoses :
CVA
Main neuropsychological/psychological
problem(s) identified.
Psychometric assessment to delineate
cognitive profile, assessment of
psychological state of child and family.
Intervention (education re CVA) with
child, consultancy to, local education and
health professionals. Advice to family.
Cognitive impairment - reduced speed of
processing, reading and writing problems,
poor attention, visual memory & visuomotor skills, fatigue. Anxiety in all family
members.
WISC - III, WORD, WOLD, CMS, NEPSY,
clinical assessment of mood & Ch IES,
SCAS & BDS
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2
3
Type of neuropsychology involvement (e.g.,
screening assessment, assessment to aid
diagnosis, rehabilitation) - list all
Assessments used (list tests, brief summary of
any other types of assessment)
Clinical Activity
Face-to face contacts (number and total
time)
5 sessions with client - total 9 hours
5 face-to face with parents & sibs - 6 hrs.
3 telephone contacts with family –1hr
1 face-to face with class teacher 1 hr, 1
telephone contacts with school- ½ hr.1
face-to-face with Ed Psych 1 hr 2
telephone contacts-1 hr.
Case Conference with local health &
education services and family. Advice
provided for assessment of special needs.
Discharged. Review by Ed Psych.
Contacts with family or carers/friends
(number, relationship and time)
Contacts with other professions (nature
and extent)
Other activity (nature and extent)
Outcome/outputs
The above record accurately reflects the candidate's work with this client.
Signed and dated ……………………………………………………….. (candidate)
Signed and dated ……………………………………………………….. (supervisor)
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