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Case conceptualization outline template

Case Conceptualization Form
Case Conceptualization Outline
The following outline is offered as an aid to conceptualizing a client’s case. Used carefully, the outline
can help a mental health clinician organize thoughts about the client as well as presenting issues, and
treatment planning.
Background information
Demographic information, such as age, grade in school, employment status, family unit information, and other
history such as (college, military, and/or current or past legal problems) that is relevant to the presenting
Presenting problem: What are the presenting issues - from the client's perspective? From your
Was there a precipitating set of circumstances? How long has the problem(s) persisted?
If third parties are involved, what are reported observations and concerns?
Describe at least one multicultural or diversity consideration you have made while working with this
client. Explain how and why you have determined the considerations.
Conceptualization of Problem
What is your view of the problem? What are the common themes?
What are the client's barriers to growth and coping skills?
Case Conceptualization Form
What are clients’ strengths/assets (protective factors/signs of resilience)?
What is the etiology of the client's present psychological capacity or incapacity?
What are your counseling goals with the client?
Theoretical Orientation:
Describe your theoretical orientation. Provide a rationale for the orientation chosen, based
upon the client’s problem, clinical presentation, and/or diagnoses. Include literature that
demonstrates how the orientation chosen matches the client’s diagnoses or treatment issues.
Please complete this section similar to a research paper, citing a minimum of 3 appropriate
references and a minimum of two paragraphs.
DSM-5 Diagnosis:
Describe at least two primary diagnoses, including any secondary diagnoses.