Download Case Formulation New 8.25.14

Case Formulation
Form (Rev. 7.9.14)
Date of First Interview:
Partner’s Name (First and Last):
Age:
Occupation:
Religious Affiliation:
Ethnicity:
Partner’s Name (First and Last):
Age:
Occupation:
Religious Affiliation:
Ethnicity:
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
Name:
Age:
Name:
Age:
Name:
Age:
Name:
Age:
Referred by:
Relation):
Relation:
Relation:
Relation:
Relation:
________
________
________
________
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, closenessdistance 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
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Individual
Couple
Intergenerational
Cultural Issues
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?