Identify significant persons in client’s relational/family life who will be mentioned in case conceptualization: Adults/Parents: Select identifier/abbreviation for use in rest of case conceptualization

Identify significant persons in client’s relational/family life who will be mentioned in case conceptualization:
Adults/Parents: Select identifier/abbreviation for use in rest of case conceptualization

: Age:       Occupation:       Other:

: Age:       Occupation:       Other:

Children/Adult Children: Select identifier/abbreviation for use in rest of case conceptualization

: Age:      Grade: Other:

: Age:      Grade: Other:

: Age:      Grade: Other:

: Age:      Grade: Other:

Others: Identify all:

Presenting Concerns
Describe each significant person’s description of the problem:

:

:

:

:

Additional:

Broader System: Description of problem from extended family, referring party, school, legal system, etc.:

Extended Family:

Name:

Name:

Background Information
Trauma/Abuse History (recent and past):

Substance Use/Abuse (current and past; self, family of origin, significant others):

Precipitating Events (recent life changes, first symptoms, stressors, etc.):

Related Historical Background (family history, related issues, previous counseling, medical/mental health history, etc.):

Client/Family Strengths and Social Location
Strengths and Resources:

Personal:

Relational/Social:

Spiritual:

Based on the client’s social location—age, gender race, ethnicity, sexual orientation, gender identity, social class, religion, geographic region, language, family configuration, abilities, etc.–identify potential resources and challenges:

Unique Resources:

Potential Challenges:

Family Structure
Family Life Cycle Stage (Check all that apply):

|_| Single Adult

|_| Committed Couple

|_| Family with Young Children

|_| Family with Adolescent Children

|_| Divorce

|_| Blended Family

|_| Launching Children

|_| Later Life

Describe struggles with mastering developmental tasks in one or more of these stages:

Boundaries with/between:

Primary couple |_| Enmeshed |_| Clear |_| Disengaged |_| NA Example:

& Children |_| Enmeshed |_| Clear |_| Disengaged |_| NA Example:

& Children |_| Enmeshed |_| Clear |_| Disengaged |_| NA Example:

Siblings |_| Enmeshed |_| Clear |_| Disengaged |_| NA Example:

Extended Family |_| Enmeshed |_| Clear |_| Disengaged |_| NA Example:

Friends/Peers/Others |_| Enmeshed |_| Clear |_| Disengaged |_| NA Example:

Triangles/Coalitions:

|_| Cross-generational coalitions: Describe:

|_| Other coalitions:

Hierarchy between Parents and Children: |_| NA

: |_|Effective |_|Insufficient (permissive) |_| Excessive (authoritarian) |_| Inconsistent

: |_|Effective |_|Insufficient (permissive) |_| Excessive (authoritarian) |_| Inconsistent

Description/Example to illustrate hierarchy:

Complementary Patterns between       and      :

|_| Pursuer/distancer

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