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7 Act Simple Case Formulation Blank

The document is a case formulation blank used by the Melbourne ACT Peer Supervision Group. It includes fields to record information about the client, counselor, number of sessions, diagnosis, client background and presenting issues. It also lists 6 questions to guide formulation of the client's case - including identifying fused and unworkable thoughts, values the client is removed from, experiences the client is avoiding, the client's story about self, quality of the client's presence and contact with the present moment, and areas where the client fails to start or finish committed actions. Counselors would fill out this form to develop a formulation of each client's case.

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Liz Rox
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393 views2 pages

7 Act Simple Case Formulation Blank

The document is a case formulation blank used by the Melbourne ACT Peer Supervision Group. It includes fields to record information about the client, counselor, number of sessions, diagnosis, client background and presenting issues. It also lists 6 questions to guide formulation of the client's case - including identifying fused and unworkable thoughts, values the client is removed from, experiences the client is avoiding, the client's story about self, quality of the client's presence and contact with the present moment, and areas where the client fails to start or finish committed actions. Counselors would fill out this form to develop a formulation of each client's case.

Uploaded by

Liz Rox
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Melbourne ACT Peer Supervision Group

ACT Simple Case Formulation Blank


Client: ______________________ Counsellor: ___________________________

# Sessions completed: __ Dx? ____________________________________

Client Background and presenting issues:


_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

Case Formulation Questions


1. What thoughts or feelings are fused and unworkable? (Fusion)
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

2. What values is the client removed from? (Remoteness from values)


___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

3. What experiences such as emotions, thoughts, reminders, contexts and


behaviours is the client avoiding or having difficulty accepting (Experiential
avoidance or unwillingness)?
___________________________________________________________
___________________________________________________________

Macintosh HD:Users:julian:Desktop:Counselling College 250709:7 ACT Simple Case


Formulation Blank.doc
Melbourne ACT Peer Supervision Group

___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

4. What is the client’s story about self? (Self as Content)


___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

5. What is the quality of the client’s presence? How do they absent themselves
from life, engagement or connection? (Contact with the present moment)
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

6. What does the client fail to start or fail to finish? Where does the client fail to
or lose focus, or fail to engage in committed action? (Committed Action)
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

Macintosh HD:Users:julian:Desktop:Counselling College 250709:7 ACT Simple Case


Formulation Blank.doc

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