CASE CONCEPTUALIZATION

Client: [Initials or ID, age, gender]
Date: [Date]
Clinician: [Name, credentials]
Based on: [Sessions so far, measures, records, collateral]

PRESENTING PROBLEMS
Problems: [Each problem in specific terms: symptoms, behaviors, impact]
Severity: [Scores such as the PHQ-9, GAD-7, or a disorder-specific scale]
Working diagnosis: [Diagnosis, if any]

THE 4 PS
Predisposing: [What made the client vulnerable: temperament, family history, early experiences, learning]
Precipitating: [What triggered the current episode, and when]
Perpetuating: [What keeps the problems going: avoidance, safety behaviors, thinking habits, circumstances]
Protective: [Strengths, supports, and resources]

COGNITIVE-BEHAVIORAL FORMULATION
Core beliefs: [About self, others, and the world]
Rules and assumptions: [The if-then rules the client lives by]
Typical trigger: [A recent, specific situation]
Automatic thoughts: [What went through the client's mind]
Emotions and body sensations: [What the client felt, and how strongly]
Behaviors: [What the client did, including avoidance and safety behaviors]
Maintaining cycle: [How these links keep the problem going]

CULTURAL AND CONTEXTUAL FACTORS
Culture and identity: [How culture, identity, faith, and community shape the problem and help-seeking]
Context: [Family, work, school, money, or systemic factors, including discrimination]

HYPOTHESES
Working hypothesis: [One or two sentences tying the 4 Ps and the cycle together]
To test: [What would support or change the hypothesis]

TREATMENT IMPLICATIONS
Targets: [What to change first, and why]
Approach: [Interventions that fit the formulation]
Possible obstacles: [What may get in the way, and how to respond]
Tracking: [Measures and how often]
Risk: [Current risk and how it will be monitored]

Signed: [Clinician name, credentials, date and time]