CASE CONCEPTUALIZATION FORMAT

I. Identifying Data: This section will include relevant demographic information.

1. Age
2. Gender
3. Race
4. University classification
5. Living situation
6. Manner of dress
7. Physical appearance
8. General Self- presentation
II. Presenting Problem: This section should include listing of the problem areas, from the
client’s
perspective, noting particularly the client’s view of their order of importance. Suggested items to
focus upon:
1. Was there a precipitating set of circumstances?
2. How long has the problem persisted?
3. Has this problem occurred before? What were the circumstances at the time?
III. Relevant History: This section will vary in comprehensiveness according to depth and
length
of counseling, and will vary in focus according to theoretical orientation and specific nature of
the
problem/s.
IV. Interpersonal Style: This section should include a description of the client’s orientation
toward
others in his environment and should include two sections:
a. Is there an overall posture he/she takes toward others? What is the nature of his typical
relationships? Karen Horney’s conceptualization may be useful here:
1. Moving toward (dependency, submission)
2. Moving against (aggressive, dominance)
3. Moving away (withdrawal)
b. How is the client’s interpersonal stance manifested specifically within the therapeutic
dyad? What is the client’s interpersonal orientation toward the counselor?
IV. Personality Dynamics
A. Cognitive Factors: This section will include any data relevant to thinking and mental
processes such are:
1. Intelligence
2. Mental alertness
3. Persistence of negative cognitions
4. Positive cognitions
5. Nature and content of fantasy life
6. Level of insight – client’s psychological mindedness or ability to be aware and
observant to changes in feeling state and behavior
7. Capacity for judgement – client’s ability to make decisions and to carry out the practical
affairs of daily living
B. Emotional Factors
1. Typical and most common emotional state
2. Mood during interviews
3. Appropriateness of affect
4. Range of emotions the client has the capacity to display
5. Cyclical aspect of the client’s emotional life
C. Behavioral Factors
1. Psychosomatic symptoms
2. Other physical related symptoms
3. Existence of persistent habits or mannerism
4. Sexual functioning
5. Eating patterns
6. Sleeping patterns
VI. Environmental Factors: This section include:
1. Elements in the environment which function as stressors for the client, both those centrally
related to the problem and more peripheral stressors.
2. Elements in the environment which function as support for the client: friends, family, living
accommodations, recreational activities, financial situation.
VII. Conceptualization of the Problems: This section will include the 5P’s and the summary of
conceptualization
1. Presenting Problem
2. Predisposing Factors
3. Precipitating Factors
4. Perpetuating Factors
5. Protective Factors
6. Case Conceptualization
VIII. Treatment Plan: Based on the above information, describe the plan you will follow to
address
the presenting and emerging problem of your client. Make it consistent with your theoretical
orientation.
VI. References: Include all the references and citations that you used in your research and case
conceptualization.