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  • 7 Act Simple Case Formulation Blank

    Transféré par

    Liz Rox
    85 vues2 pages
    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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    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.

    Droits d'auteur :

    © All Rights Reserved
    Téléchargez comme PDF, TXT ou lisez en ligne sur Scribd
    Signaler comme contenu inapproprié
    85 vues2 pages

    7 Act Simple Case Formulation Blank

    Transféré par

    Liz Rox
    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.

    Droits d'auteur :

    © All Rights Reserved
    Téléchargez comme PDF, TXT ou lisez en ligne sur Scribd
    Signaler comme contenu inapproprié
    sur 2

    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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