Psychological report example and Word template

I am referring [Name], a 34-year-old woman who has been in cognitive behavioural therapy with me for five months (14 sessions). I would be grateful for a psychiatric assessment of whether pharmacological treatment could support the current therapy.

Her worry has clearly improved, but her insomnia persists (ISI 18) and her mood has worsened over the past month (PHQ-9 from 8 to 12). I would particularly value your view on the insomnia and the depressive component.

[Name] works as a project coordinator at a logistics company and lives with her partner; she has no children. She self-referred with constant worry about her work performance, about making mistakes and about her parents' health, together with neck and shoulder tension and difficulty falling asleep. She reports that this began about eight months before her first appointment, after a promotion to team lead.

She has had no previous psychological or psychiatric treatment, takes no medication and reports no relevant medical history. She has not had a medical check-up in the last two years. At intake she described having a glass of wine most nights to help her sleep; she stopped during the first months of therapy and currently reports no alcohol use.

Assessment comprised clinical interview, self-monitoring diaries for worry and sleep, and three self-report questionnaires: GAD-7, PHQ-9 and the Insomnia Severity Index (ISI).

The scores suggest anxiety falling from the severe to the moderate range, insomnia remaining in the moderate clinical range and depressive symptoms rising to the moderate range, coinciding with a conflict at work. Her sleep diaries show sleep onset taking over an hour on most nights.

Provisional diagnosis: generalised anxiety disorder (ICD-10 F41.1) with non-organic insomnia (ICD-10 F51.0). I leave open whether the recent depressive symptoms represent a distinct presentation.

• Intake ([date]): GAD-7 16; PHQ-9 8; ISI 19.
• Session 12 ([date]): GAD-7 11; PHQ-9 12; ISI 18.

I understand her difficulties as a worry cycle maintained by beliefs about responsibility and the need not to make mistakes, activated by the greater demands of her new role. Faced with uncertainty, [Name] checks email late at night, over-prepares for meetings, seeks reassurance from colleagues and avoids delegating. These behaviours relieve anxiety in the short term but stop her learning that she can tolerate uncertainty, and they add to her workload.

Her insomnia is maintained by mental arousal at bedtime, phone use in bed and an irregular sleep schedule; the wine served as a short-term way of managing this. Giving up rewarding activities (she stopped running at weekends), accumulated tiredness and the recent conflict at work are likely contributors to the drop in mood.

Weekly cognitive behavioural therapy: psychoeducation on anxiety and sleep, worry monitoring and postponement, cognitive restructuring of beliefs about mistakes, behavioural experiments (delegating tasks, reducing meeting preparation and reassurance seeking) and problem solving. Since session 6 I have used components of cognitive behavioural therapy for insomnia: stimulus control and sleep scheduling.

[Name] has clearly reduced late-night email checking and reassurance seeking, now delegates some tasks and has stopped drinking wine at night. However, sleep onset has barely changed despite reasonable adherence, and since the conflict at work she reports low mood, tiredness and reduced interest. We have started behavioural activation, including a gradual return to running.

I explored suicidal ideation and self-harm at intake and again at session 12, when I noticed the drop in mood, using direct questions and a review of PHQ-9 item 9 (scored 0 on both occasions). [Name] denies current or past suicidal ideation and has no history of self-harm.

Protective factors include the support of her partner and close friends and good engagement with treatment. I continue to review risk at every session.

I have advised [Name] to book a check-up with her family doctor (GP), given the time since her last one. I will continue weekly therapy and can send updated measures before your appointment. I am available on [phone or email] to discuss her care.

• Assessment of the persistent insomnia and the recent depressive symptoms, including differential diagnosis.
• Your view on whether pharmacological treatment could support the ongoing cognitive behavioural therapy.
• A brief report of your assessment so that we can adjust the treatment plan together.

I am issuing this report as the clinician responsible for her treatment, with the explicit consent of [Name], who read it before it was sent. It contains only the clinical information needed for the assessment requested. It is confidential and should not be used for any other purpose or shared with third parties without her permission.