ICD-10 code for psychosis
This free case conceptualization worksheet provides mental health therapists with an overview of the key information to summarize in a psychological evaluation, along with examples.
We’ve also included a free downloadable case conceptualization template that you can save to your electronic health record (EHR) to aid in treatment planning.
What is case conceptualization?
Case conceptualization, or case formulation, is integral to therapy and treatment planning.
Research shows that there appears to be a link between high-quality case conceptualization and therapy outcomes.
This process seeks to establish an effective and collaborative therapeutic alliance by understanding the client’s unique history, challenges, and presenting issues.
In turn, it can empower the client to understand themselves better and engage in treatment.
However, case conceptualization is a complex skill that takes time to develop. This is where using a case conceptualization worksheet or case conceptualization template with clients can be helpful.
In a case conceptualization, clinicians organize client information into a succinct clinical summary that provides an individualized understanding (or hypothesis) of the factors influencing the client’s challenges. It also helps clinicians formulate a diagnosis and treatment plan.
What to include in your case conceptualization
The main components of case conceptualization include:
Presenting problem(s)
This section of the case formulation template should include the reason the client is seeking therapy, including a description of their symptoms, behaviors, or challenges, history and development of the problem, duration, severity, and the impact on functioning.
Some clinicians may also choose to include the ICD-10 diagnosis code for the client’s diagnosis and their specific symptoms.
Example: “The client is a 25-year-old female college student experiencing severe panic attacks in school. Symptoms began in school and worsened in college due to academic pressure and social anxiety. The client meets the ICD-10 diagnosis code for panic disorder [episodic paroxysmal anxiety] (code F41.0) and generalized anxiety disorder (code F41.1) as evidenced by symptoms including…”
History
The history section involves using a biopsychosocial framework to understand the client’s challenges, risk factors, and relationships.
Biological: Genetic, familial, temperament, and medical factors. For example, a family history of mental health conditions and/or substance use.
Psychological: Core beliefs regarding themselves that may inform their self-esteem and confidence, as well as challenges, such as limited social or communication skills.
Social: Childhood loss, parenting experience, family dynamics, relationships, and messaging. Stressors and environmental risk factors may include cultural, work, lack of social support, grief and loss, school, stability (housing), and access to resources.
Example: “The client has a history of childhood trauma, with an ACE score of 6. They reported mental health conditions and substance use in their family of origin and experienced high parental expectations. The client has limited social support and experiences financial stress.”
Protective factors and strengths
The client's strengths, such as resilience, enable them to adapt to challenges.
Protective factors can decrease the likelihood of developing a clinical condition. Factors include coping skills, secure attachments, a positive support system, academic competence, self-determination, access to healthcare and financial resources, problem-solving skills, housing, cultural, spiritual, or religious beliefs, and responsibilities (children, employment).
Example: “The client demonstrated resilience, is hardworking, and has access to resources. Despite their anxiety and panic, they have academic competence, stable housing, and some close friendships which they find supportive.”
Patterns
This section of the case conceptualization template includes the client’s pattern of baseline functional and dysfunctional thoughts, feelings, and behavior when under stress and nonstressful circumstances.
Example: “The client reported a tendency to catastrophize failure, have low self-esteem, and engage in avoidance behaviors to quell their anxiety.”
Perpetuants
The psychological, social, and environmental factors that reinforce the client’s pattern.
Example: Using addictive substances to cope with anxiety and a lack of positive social support may perpetuate the client’s presenting problem.
Treatment goals, interventions, and plan
Goals: The goals the client would like to achieve with treatment, ideally including their quotes.
Interventions: The specific interventions or strategies the clinician believes will help to address the client’s presenting issues.
Plan: The treatment approach, including modalities, frequency of sessions, duration of treatment, and any referrals.
Example: Once weekly therapy with this clinician using a combination of cognitive behavioral therapy, strengths-based counseling, and dialectical behavioral therapy to address maladaptive thoughts and strengthen distress tolerance and emotional regulation skills. Once a therapeutic alliance has been established, treatment may also include eye movement desensitization and reprocessing therapy (EMDR) to address childhood traumas.
Prognosis
The client’s anticipated response to treatment, which may include likelihood of improvement, potential setbacks, and long-term outlook based on factors like symptom severity, strengths, risks, protective factors, and readiness for change.
Example: “The client is anticipated to respond well to treatment based on her readiness for change and integration of her strengths and protective factors into the treatment approach.”
While this example uses a biopsychosocial framework, the components of a case conceptualization worksheet may differ depending on the theoretical framework and modality the clinician uses.
The following section illustrates these approaches with examples of cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT).
Case formulation examples
Below you will find two examples using an ACT and CBT approach to case conceptualization.
ACT case formulation template example
Client: Alex, 30, struggles with anxiety and avoidance, particularly in work and social settings.
Core issues:
Cognitive fusion: Believes “I’m not good enough,” leading to avoidance.
Experiential avoidance: Suppresses anxiety rather than accepting it.
Lack of values-driven action: Avoids discomfort instead of pursuing meaningful goals.
ACT treatment focus:
Cognitive defusion and acceptance: Help Alex detach from unhelpful thoughts and tolerate discomfort.
Mindfulness and present-moment awareness: Reduce overthinking and increase engagement.
Values clarification and committed action: Shift from avoidance to meaningful behaviors.
Potential challenges: The client’s resistance to discomfort and strong avoidance habits. Strategies include normalizing discomfort and gradual exposure.
Prognosis: Positive if Alex engages in ACT techniques; slower progress if avoidance persists.
CBT case conceptualization worksheet example
Client: Alex, 30, experiences anxiety and avoidance, especially in work and social situations.
Core issues:
Negative automatic thoughts: “I’m not good enough,” leading to self-doubt and avoidance.
Cognitive distortions: Catastrophizing failure and overgeneralizing past mistakes.
Behavioral avoidance: Procrastinates and withdraws to escape discomfort.
CBT treatment focus:
Cognitive restructuring: Identify and challenge unhelpful thoughts.
Behavioral activation and exposure: Gradual engagement in avoided tasks and situations.
Coping skills training: Develop problem-solving and relaxation techniques.
Potential challenges: Resistance to change, high anxiety in exposure tasks. Addressed through gradual desensitization and reinforcing small successes.
Prognosis: Positive if Alex practices new skills; slower if avoidance remains dominant.
How to use the case conceptualization worksheet
You can download and use the case conceptualization template in several ways.
For example, you can download or print the case conceptualization worksheet and use it to take notes during your assessment in your virtual or in-person session.
Another way to use the case conceptualization worksheet is to reflect on areas you may want to ask follow-up questions about.
The template could also inform your intake paperwork, allowing you to gather valuable insights before meeting your client for the first time.
Lastly, you may use the case conceptualization template in supervision sessions as a training tool.
Sources
Beck Institute. (2020). Case Write-up Worksheet. Beck Institute.
Gilboa-Schechtman E. (2024). Case Conceptualization in Clinical Practice and Training. Clinical psychology in Europe.
Padesky, C. A. (2020). Collaborative case conceptualization: Client knows best. Cognitive and Behavioral Practice.
Sperry, J., Sperry, L. (2020). Case conceptualization: Key to highly effective counseling. American Counseling Association.
Sokol, L., & Fox, M. G. (2020). The Comprehensive Clinician’s Guide to Cognitive Behavioral therapy. PESI.
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