What is case formulation?

As mentioned previously, a case formulation (or conceptualization) compiles the essential facts and findings from an evaluation to inform recommendations. It typically covers five important aspects of the case and will be informed depending on the therapeutic intervention that you are trained in and use. 

1. Presenting issue that the client has come to see you for and to seek treatment about. It can be helpful to include how and why the client was referred to you in this section. 
2. Background Information about the client, their history, and a rough timeline of events that are relevant to the presenting issue. It can also include things like the client’s gender, age, level of education, vocational status, number of dependants and marital status. 
3. Protective factors and strengths that prevent the situation from getting worse. What are the positive factors supporting the client. This can include things like physical health, family support, financial resources, capacity to work, resilience or other positive personality traits, emotional stability, willingness to heal, personal insight and awareness etc. 
4. Limitations and other factors that sustain the issue or make it worse.