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 4 5 9 10 12 16 18 19 20 21 22 23 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 9 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) 10 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. 12 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 13 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: .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. 14 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. 16 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 18 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. 19 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) 20 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 1 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) 25