CBT Case Conceptualization (Cognitive Model)

Patient name/identifier, DOB, pronouns: [Patient identifier / DOB / pronouns] (For any field not collected, write "Not collected.")

Clinician name, credentials; supervisor if applicable: [Clinician name, credentials; Supervisor name/credentials if applicable]

Conceptualization date; revision date and rationale if updated: [Initial formulation date; Revision date(s) and brief rationale]

Encounter date(s) informing this formulation: [Encounter date(s)]

Setting: [outpatient / inpatient / partial hospital / IOP] — [individual / couple / family / group]

Data sources: [patient report / collateral / chart review / standardized measures]

Presenting Concerns and Clinical Context

[Why now / referral question] (Open with 1–2 sentences stating the chief concern or referral question and precipitating context.)

[Primary symptom clusters with timeframe] (Summarize key symptom domains, onset/duration, frequency, and severity.)

• Functional impact—Work/School: [Impact on performance, attendance, productivity]
• Functional impact—Relationships: [Impact on family, peers, intimate relationships, social engagement]
• Functional impact—Self-care/ADLs: [Nutrition, hygiene, daily structure, activities]
• Sleep: [Onset, maintenance, duration, quality, circadian pattern]
• Substance use: [Type, frequency, quantity, context, recent changes]
• Current medications and concurrent treatments: [Relevant medications with doses; concurrent therapy or programs] (Include only if relevant to CBT work.)

Risk snapshot: [Suicidal ideation / Self-harm / Homicidal ideation / Psychosis / Mania status and protective factors] (If risk not assessed this session: "Risk assessment: Not completed this session—[reason].")

(If this is a mid-treatment update, focus on changes since prior formulation and reference prior documentation for baseline.)

Problem List and Treatment Aims

(List CBT target problems ordered by: 1) safety/acuity, 2) functional impairment, 3) patient priority/readiness. Use behaviorally anchored, transdiagnostic statements.)

• Problem 1: [Behaviorally anchored problem statement]
  • Observable pattern: [What is seen/measured]
  • Typical triggers/contexts: [1–3 triggers or contexts]
  • Maintaining loop: [Cognition ↔ emotion/physiology ↔ behavior ↔ consequence]
  • Baseline severity: [Patient rating 0–10 or validated measure score]
  • Initial treatment aim: [Measurable target outcome and timeframe]
• Problem 2: [Behaviorally anchored problem statement]
  • Observable pattern: [What is seen/measured]
  • Typical triggers/contexts: [1–3 triggers or contexts]
  • Maintaining loop: [Cognition ↔ emotion/physiology ↔ behavior ↔ consequence]
  • Baseline severity: [Patient rating 0–10 or validated measure score]
  • Initial treatment aim: [Measurable target outcome and timeframe]

(If patient cannot yet prioritize: "Prioritization deferred—will revisit after psychoeducation/monitoring.")

Cross-Sectional Cognitive Model

Pattern Summary

[3–6 sentence loop summary: situations → automatic thoughts/meanings → emotions/physiology → behaviors → consequences] (Label inferential content as "Formulation Hypothesis.")

Situation Maps

(Document 2–3 representative situations. Use brief direct quotes for automatic thoughts in patient language.)

• Situation 1
  • Situation/Trigger: [Context/event]
  • Automatic Thoughts: ["Quoted thought" — belief rating 0–100% if available]
  • Meaning/Appraisal: [What the thought implies about self/others/world]
  • Emotions: [Emotion label — intensity 0–100]
  • Physiological sensations: [Body cues] (Include when relevant, especially for panic, trauma, anger, somatic presentations.)
  • Behavioral response: [Avoidance / safety behavior / reassurance seeking / checking / withdrawal / other maintaining behavior]
  • Consequences: [Immediate effects; longer-term effects]
  • Candidate alternative response: [Adaptive thought/behavior] (Optional; include once treatment is underway.)
• Situation 2
  • Situation/Trigger: [Context/event]
  • Automatic Thoughts: ["Quoted thought" — belief rating 0–100% if available]
  • Meaning/Appraisal: [What the thought implies about self/others/world]
  • Emotions: [Emotion label — intensity 0–100]
  • Physiological sensations: [Body cues]
  • Behavioral response: [Maintaining behavior]
  • Consequences: [Immediate effects; longer-term effects]
  • Candidate alternative response: [Adaptive thought/behavior] (Optional.)

(Add Situation 3 if needed.)

High-Risk Chain Analysis

(Include ONLY when self-harm urges, suicidality, substance relapse, violence risk, severe dissociation, or binge/purge behaviors are present. Omit entire subsection if not applicable.)

• Vulnerabilities: [Sleep loss, substances, interpersonal stressors, medical issues, anniversaries]
• Prompting event: [Trigger]
• Links (thoughts → emotions → body): [Stepwise escalation]
• Behavior: [High-risk act or near-miss]
• After-effects: [Immediate relief/costs; longer-term outcomes]
• Intervention points: [Where to interrupt chain; skills or supports to apply]

Longitudinal Conceptualization

Relevant History

[Developmental, relational, cultural, trauma, and medical history relevant to current beliefs/coping] (Distinguish patient report vs. records/collateral. Document clinically relevant elements without detailed traumatic content. If not yet assessed: "Not yet assessed—[reason].")

Belief Structure

• Core beliefs (self/others/world): [Hypothesized beliefs] (Note whether patient endorses or clinician hypothesis.)
• Intermediate beliefs—Rules, assumptions: ["If...then..." and "should/must" statements]
• Compensatory strategies: [Avoidance / perfectionism / people-pleasing / control / other] (Link each to relevant belief.)

Strengths and Adaptive Patterns

• Adaptive beliefs/values: [Values, identity anchors, worldviews that support coping]
• Effective coping patterns: [Skills or strategies that work, and in what contexts]
• Exceptions: [Times the problem is less intense and what differs]

Maintaining Factors

(Include only categories with identified factors. Write "Not assessed" for domains not evaluated.)

• Cognitive: [Attentional bias / threat appraisal / rumination / self-criticism]
• Behavioral: [Avoidance / safety behaviors / reassurance seeking / inactivity / sleep disruption]
• Emotional/physiological: [High arousal / low distress tolerance / dissociation]
• Interpersonal/systemic: [Conflict cycles / accommodation by others / environmental stressors]
• Therapy-interfering: [Homework barriers / attendance issues / competing demands / ambivalence]

Protective Factors and Resources

• Internal strengths: [Skills, prior successes, coping efficacy, reasons for living]
• External supports: [Relationships, community/spiritual resources, workplace/school supports]
• Safety/protective factors: [Treatment engagement, crisis supports access, means safety]

Treatment Plan

Working Formulation Statement

Working Hypothesis: [3–8 sentences linking problems → triggers → automatic thoughts/meanings → emotions/physiology → behaviors → consequences → underlying beliefs → maintaining factors]

Prioritized CBT Targets

(Align numbering with Problem List.)

• Target 1: [Specific behavior/cognition/process] — Rationale: [Maintaining factor addressed] — Barriers/Mitigation: [Anticipated barriers and plan]
• Target 2: [Specific behavior/cognition/process] — Rationale: [Maintaining factor addressed] — Barriers/Mitigation: [Anticipated barriers and plan]

Planned Interventions

(Select applicable interventions; link each to the maintaining cycle or belief level it addresses.)

• [Psychoeducation]
• [Behavioral activation / activity scheduling]
• [Exposure (in vivo / imaginal / interoceptive) with safety behavior reduction]
• [Cognitive restructuring / thought records]
• [Behavioral experiments]
• [Skills training (emotion regulation / distress tolerance / problem-solving)]
• [Sleep intervention / stimulus control]
• [Relapse prevention / coping planning]

Measurement Plan

[Selected measures, frequency, and target thresholds if applicable]

Between-Session Practice

(Include when a specific action plan was agreed. Omit if no homework assigned.)

• Task: [What to practice] — Frequency: [How often] — Predicted obstacles: [Barriers] — Review plan: [How results will be reviewed]

Coordination and Consent

(Include when coordinating with other providers. Omit if none.)

• Consent: [obtained / declined / not yet discussed]
• Information to share: [Domains and recipients] — Purpose: [Reason for coordination]

Safety Plan Reference

(Include when elevated risk or prior self-harm/suicide attempts. Omit if not applicable.)

• Safety plan location/date: [Where documented]
• Crisis resources: [Hotline / local crisis services / urgent contact instructions]

Patient Collaboration

[Whether formulation was shared with patient; their agreement/disagreement and edits in their own words; planned date to review/update]

Authentication

Clinician signature, credentials: [Signature]

Date/Time: [Date and time]

(Documentation guidance: Use patient language for automatic thoughts. Distinguish patient-reported information, observed behavior, and clinician inference—label inferences as "Formulation Hypothesis." Omit conditional sections when not applicable; do not include empty placeholders.)