Case Formulation Form (Rev. 7.9.14)

Date of First Interview:

Partner’s Name (First and Last): Age:

Occupation: Ethnicity:

Religious Affiliation:

Partner’s Name (First and Last): Age:

Occupation: Ethnicity:

Religious Affiliation:

Years Married/In Relationship:

Children: Name: Age: Lives with you? Yes No

Name: Age: Lives with you? Yes No

Name: Age: Lives with you? Yes No

Name: Age: Lives with you? Yes No

Name: Age: Lives with you? Yes No

Name: Age: Lives with you? Yes No

Other Family in Home (Name, Age, and Relation):

Name: Age: Relation: ______

Name: Age: Relation: ______

Name: Age: Relation: ______

Name: Age: Relation: ______

Referred by: Reason for Referral:

1. Initial impressions and reactions:

2. Precipitating event(s) that motivated them to seek treatment at this particular time:

3. Presenting problem(s)—give a concrete description, including who, where, what, how. What is each member’s view of the problem? How is the problem maintained in the system?

4. History of the problem—abbreviated form of #3, above:

5. Solutions attempted—including previous therapy:

6. Changes sought by client(s) (each client, couple goals):

7. Any recent significant changes—stressors and life-cycle changes (e.g., new job, move, death, divorce, child leaving home, etc.):

B. Predisposing Events and Conditions

8. What are the strengths in the system?

IntersystemAssessment Questions

9. Individual system(s) (e.g. psychological domain: cognitive distortions and irrational thinking, defense mechanisms such as denial, projection; definitions, predictions, beliefs, expectations, interpretations, past trauma’s, addictions (substance and process) problematic traits and attributes, ability to regulate emotion, coping style, DSM5 diagnoses):

Biologic Domain: (physical illness, chronic, acute, perception of and reaction to illness, prognosis, treatment, medications, mental illness not attributed to psychological causes, anxiety/worries over health):

10. Couple system (e.g., styles of communication; patterns and circular sequences of dyadic interaction; linear attribution strategies such as blaming, justification, vilification, rationalization, or debilitation; conflict resolution skills; emotional contracts, effect of behavior on others (real and imagined), interplay of attachment styles, relational skill deficits, level of commitment, fears of intimacy):

11. Intergenerational system (e.g., scripts, boundaries, cutoffs, triangles, closeness-distance or individuation issues, anniversary reactions, early attachment style, timeline of important life-cycle events, internal working models, etc.):

12. External influences: (e.g. effect of culture, religion, societal norms, economic, political, geographic, climatic, natural and man-made disasters):

Treatment Plan Questions

1. Hypothesis regarding the client(s) based on theoretical or conceptual model.

2. Treatment plan and strategies (individuals, couple, intergenerational).

Problems / Change Strategy or Technique / Theory
Individual
1.
2.
3. / 1.
2.
3. / 1.
2.
3.
Couple
1.
2.
3. / 1.
2.
3. / 1.
2.
3.
Intergenerational
1.
2.
3. / 1.
2.
3. / 1.
2.
3.
Cultural Issues
1.
2.
3. / 1.
2.
3. / 1.
2.
3.

3. What is your relapse prevention plan?

4. Prognosis and expected length of therapy (provisional):

5. What are your professional and personal strengths and weakness in dealing with this client system?

6. What ethical and/or professional issues exist or may exist with this case (e.g., attraction or dislike of client-system, divorce and custody potential, dual relationships, practicing beyond scope of practice)?

7. Any other issues or concerns pertinent to this case (e.g., involvement with macro institutions, such as psychiatric/medical personnel, educational institutions, legal issues, social service agencies, child protective services)?

8. Does this patient have the potential for suicide? What are the indicators? Did you document a suicide contract and safety plan and contact your supervisor immediately as well as follow Center policies?

Self-Assessment of Case Formulation

1. Did you develop a comprehensive formulation?

2. Did you elaborate on symptoms or problems, identify stressors and predisposing/precipitating events?

3. Did you develop a hypothesis based on a theory that would suggest a treatment approach?

4. Did you capture the complexity of the client-system?

5. Did you use precise and descriptive language?

6. Did you demonstrate the ability to draw inferences from the raw data?