Psychologist Template

Child assessment session

A professional Psychologist template for healthcare professionals.

About this template

Need a comprehensive way to document child assessments? This child assessment session template is perfect for psychologists and other mental health professionals. It provides a structured framework for recording observations, exploring emotional needs, and formulating recommendations. This template helps you capture crucial details about a child's presentation, emotional state, and support needs. With Heidi, this template can be easily populated from your session transcript, saving you time and ensuring thorough documentation. Get organised and improve your clinical notes today!

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Assessment Session Context of the Session: A 45-minute semi-structured session was carried out with Emily Carter, aged 8, in a quiet room at her foster home on 1 November 2024. The session was trauma-focused and aimed to explore Emily’s emotional needs at home and school. The assessment was requested by Social Services, in the context of Emily's experiences as a looked-after child and ongoing emotional and behavioural concerns. Engagement & Presentation: Emily presented as initially withdrawn, but she engaged well with the use of a calming sensory bottle. Her general mood was subdued, and she displayed signs of anxiety, such as fidgeting and avoiding eye contact. She was able to maintain focus for the duration of the session. Exploration of Emotional Needs: * Emily was able to name and identify some of her feelings, such as sadness and anger, but struggled to locate them in her body. * She used a colour-based emotion tool to express her feelings, with the colour blue representing sadness and red representing anger. * Patterns in emotion expression included difficulty regulating anger, often leading to outbursts. * Emily lives with her foster parents, who she described as “kind” and “caring.” * She disclosed feeling scared at night and missing her biological mother. * Protective factors included her love for drawing and her close relationship with her foster mother. * She likes art class at school but dislikes loud noises. * Relationships with adults and peers were described as “okay,” but she struggles to trust new people. * Areas of distress included nightmares and feeling alone. * Support strategies mentioned by Emily included talking to her foster mother and drawing. * She described managing big emotions by taking deep breaths and drawing. * She stated that being in a quiet space helps her calm down, while loud noises and arguments do not. * Her understanding of safety, control, and trust was limited, particularly in relation to new situations. * There were no signs of dissociation, but she displayed control-seeking behaviour, such as wanting to choose the activities. * Her self-identified strengths included her creativity and her ability to draw. * She is proud of her drawings and finds joy in spending time with her foster mother. * She would like adults to know that she needs someone to listen to her and understand her feelings. Clinical Impressions: Emily shows indicators of an insecure attachment style, likely stemming from her early childhood experiences. She demonstrates trauma responses, including anxiety and difficulty regulating emotions. Her emotional regulation capacity is limited, but she shows resilience through her creativity and supportive relationships. Barriers to learning and engagement are linked to her emotional needs, particularly her feelings of insecurity and fear. Recommendations: * Continue with trauma-informed therapy to address her emotional needs. * Provide a safe and consistent environment at home. * Encourage her to express her feelings through art therapy. * School-based recommendations include providing a quiet space for her to regulate her emotions and offering support from the school counsellor. * Care system input should focus on ensuring consistent contact with her foster mother and providing ongoing support to the foster family.

Assessment Session Context of the Session: [Provide a brief introduction to why the session took place, where, and with whom. Include the date and setting of the session, who was present, the purpose of the session, and the referral source.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Example: "A 45-minute semi-structured session was carried out with [child's name] in a quiet room at school on [date]. The session was trauma-focused and aimed to explore [child's name]’s emotional needs at home and school. The assessment was requested by [referrer], in the context of [child's name]'s experiences as a looked-after child and ongoing emotional and behavioural concerns." Engagement & Presentation: [Describe how the child presented emotionally and behaviourally during the session. Include initial engagement, use of regulating tools, general mood, affect, and energy, and any observable signs of anxiety, hypervigilance, withdrawal, etc.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Exploration of Emotional Needs: [Organise this into the session themes. Include the child's ability to name, identify, or locate feelings in their body, use of visual or colour-based emotion tools, patterns in emotion expression or regulation difficulties, who the child lives with and their description of this, any disclosures or indicators of distress, instability, or unmet needs at home, protective factors, likes/dislikes about school, relationships with adults and peers, areas of distress or avoidance, support strategies mentioned by the child, how the child describes managing big emotions, what helps them calm down, and what doesn’t, their understanding of safety, control, and trust, any signs of dissociation, control-seeking behaviour, or trauma triggers, the child’s self-identified strengths or interests, anything they’re proud of or find joy in, and messages they would like adults to know about helping them.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Clinical Impressions: [Provide a psychologically-informed interpretation of the child’s responses and behaviour. Include attachment style indicators, evidence of trauma responses, emotional regulation capacity, strengths or resilience observed, and any barriers to learning or engagement linked to emotional need.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Recommendations: [Focus on emotional support needs, therapeutic recommendations, school-based recommendations, and care system input.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.) all the relevant information from the transcript.)

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