a case study

: 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:      

Others: Identify all:      

Describe each significant person’s description of the problem, focusing on OBSERVABLE behaviors:

:      

:      

:      

:      

Additional:      

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

Extended Family:      

Name:      

Describe the communication and validation patterns for all significant persons related to client:

Relational dynamics that triggers survival stance:      

Relational/family belief or rule that informs this triggering dynamic:      

Relational dynamics that enable person to communicate congruently:      

: Stance(s) when feels invalidated: |_| Placating |_| Blaming |_| Superreasonable |_| Irrelevant

Relational dynamics that triggers survival stance:      

Relational/family belief or rule that informs this triggering dynamic:      

Relational dynamics that enable person to communicate congruently:      

: Stance(s) when feels invalidated: |_| Placating |_| Blaming |_| Superreasonable |_| Irrelevant

Relational dynamics that triggers survival stance:      

Relational/family belief or rule that informs this triggering dynamic:      

Relational dynamics that enable person to communicate congruently:      

: Stance(s) when feels invalidated: |_| Placating |_| Blaming |_| Superreasonable |_| Irrelevant

Relational dynamics that triggers survival stance:      

Relational/family belief or rule that informs this triggering dynamic:      

Relational dynamics that enable person to communicate congruently:      

Additional:      

Describe the dynamics of each person’s sense of self-worth and self-esteem, including contexts in which each has greater or lesser sense of worth:

:      

:      

:      

:      

Additional:      

Describe dynamics of social location, such as cultural, gender, social class, or other diversity factors, that inform evaluation of self:      

Describe significant events, specifically those that may relate to sense of validation and worth, in family and/or relational life; please list in chronological order:

Year:       Event:       Significance:      

Year:       Event:       Significance:      

Year:       Event:       Significance:      

Year:       Event:       Significance:      

Year:       Event:       Significance:      

Year:       Event:       Significance:      

Additional:      

Describe salient dynamics:

|_| Describe salient family/relational roles:

|_| Martyr:      

|_| Victim/helpless:      

|_| Rescuer:      

|_| Good/bad child:      

|_| Good/bad parent:      

|_| Other:      

Describe how client’s social location—ethnicity, race, gender, sexual orientation, social class, and other diversity factors—inform these dynamics:      

Hypothesized homeostatic function of presenting problem: How might the symptom serve to maintain connection, create independence/distance, establish influence, reestablish connection, or otherwise help create a sense of balance in the family?