Case Conceptualization Form – Fill Out and Use This PDF

Gehart Chapter 2 02/20/2009

42CHAPTER 2 Case Conceptualization

CASE CONCEPTUALIZATION FORM

I. Introduction to Client and Signiicant Others (Include age, ethnicity, occupation, grade, relevant identii ers, etc.). Put an * next to persons in session and/or IP for identiied patient.

II. Presenting Concern

Clients/Familys Descriptions of Problem(s):

Broader System Problem Descriptions (description of problem from referring party, teachers, rela- tives, legal system, etc.):

:

:

III. Background Information

Recent Background (recent life changes, precipitating events, irst symptoms, stressors, etc.):

Related Historical Background (family history, related issues, past abuse, trauma, previous coun- seling, medical/mental health history, etc.):

IV. Systemic Assessment

Client/Relational Strengths

Personal/individual:

Relational/social:

†Abbreviations: AF: Adult Female; AM: Adult Male; CF#: Child Female with age, e.g., CF15; CM#: Child Male with age; IP: Identiied Patient; Hx: History; Ex: Explanation or Example; NA: Not Applicable.

Gehart Chapter 2 02/20/2009

Spiritual:

Family Structure and Interaction Patterns

Couple Subsystem (to be assessed): □ Personal current □ Personal past □ Parents

Couple Boundaries: □ Clear □ Enmeshed □ Disengaged □ Other:

Rules for closeness/distance:

Couple Problem Interaction Pattern (A ⇄ B):

Start of tension:

Conlict/symptom escalation:

Return to “normal”/homeostasis:

Couple Complementary Patterns: □ Pursuer/distancer □ Over/under functioner

□Emotional/logical □ Good/bad parent □ Other: Describe:

Satirs Communication Stances:

AF: □ Congruent □ Placator □ Blamer □ Superreasonable □ Irrelevant

AM: □ Congruent □ Placator □ Blamer □ Superreasonable □ Irrelevant Describe dynamic:

Gottmans Divorce Indicators:

Criticism: □ AF □ AM Ex:

Defensiveness: □ AF □ AM Ex:

Contempt: □ AF □ AM Ex:

Stonewalling: □ AF □ AM Ex:

Failed repair attempts: □ AF □ AM Ex:

Not accept inluence: □ AF □ AM Ex:

Harsh startup: □ AF □ AM Ex:

Parental Subsystem: □ Family of procreation □ Family of origin

Membership in Family Subsystems: Parental: □ AF □ AM □ Other:

Is parental subsystem distinct from couple subsystem? □ Yes □ No □ NA (divorce) Sibling subsystem:

Special interest:

(continued)

Gehart Chapter 2 02/20/2009

44CHAPTER 2 Case Conceptualization

(continued)

IV. Systemic Assessment

Family Structure and Interaction Patterns

Family Life Cycle Stage:

□Single adult □ Marriage □ Family with young children

□Family with adolescent children □ Launching children □ Later life Describe struggles with mastering developmental tasks in one of these stages:

Hierarchy Between Child/Parents:

AF: □ Effective □ Insuficient (permissive) □ Excessive (authoritarian) □ Inconsistent

AM: □ Effective □ Insuficient (permissive) □ Excessive (authoritarian) □ Inconsistent

Ex:

Emotional Boundaries with Children:

AF: □ Clear/balanced □ Enmeshed (reactive) □ Disengaged (disinterested)

□Other:

AM: □ Clear/balanced □ Enmeshed (reactive) □ Disengaged (disinterested)

□Other:

Ex:

Problem Interaction Pattern (A ⇄ B):

Start of tension:

Conlict/symptom escalation:

Return to “normal”/homeostasis:

Communication Stances:

Gehart Chapter 2 02/20/2009

Hypothesis (Describe possible role or function of symptom in maintaining family homeostasis):

Intergenerational Patterns

Substance/alcohol abuse: □ NA □ Hx:

Sexual/physical/emotional abuse: □ NA □ Hx:

Parent/child relations: □ NA □ Hx:

Physical/mental disorders: □ NA □ Hx:

Historical incidents of presenting problem: □ NA □ Hx:

Family strengths:

Previous Solutions and Unique Outcomes

Solutions that DIDN

Solutions that DID work:

Narratives, Dominant Discourses, and Diversity

Dominant Discourses informing deinition of problem:

Cultural, ethnic, SES, etc.:

Gender, sex orientation, etc.:

Other social inluences:

Identity Narratives that have developed around problem for AF, AM, and/or CM/F:

Local or Preferred Discourses:

Other Inluential Discourses:

V. Genogram

Construct a family genogram and include all relevant information, including:

•ages, birth/death dates

•names

•relational patterns

•occupations

•medical history

•psychiatric disorders

•abuse history

Also include a couple of adjectives for persons frequently discussed in session (these should describe personal qualities and/or relational patterns, e.g., quiet, family caretaker, emotionally distant, perfectionist, helpless, etc.). Genogram should be attached to report.

(continued)