Stoltenberg,
C. D., McNeill, B., & Delworth, U. (1998). IDM supervision:
An integrated developmental model for supervising counselors and
therapists. (pp. 187-191) San Francisco:
Jossey-Bass.
Format is designed to help therapist collect and integrate
relevant information for case conceptualization, diagnosis,
treatment, organize client information, and facilitate discussion
leading to understanding and ultimately decision making.
1.
Clinic Data
a.
Therapist name
b.
Status (first practicum,
intern, staff)
c.
Agency / clinic site
d.
Number of sessions with
client
e.
Type of sessions
(individual, group, marital, family)
2.
Client Demographic
Data
a.
Name (initials or altered
name for confidentiality)
b.
Date of birth/age
c.
Sex
d.
Marital status
e.
Children (in and out of
home, ages, sex)
f.
Living situation
i.
House, apartment
ii.
People living in the home
and relationship with client
3.
SES Data
a.
Occupational Status
i.
Client
ii.
Family Members
iii.
Average Family Income
iv.
Transportation status
(drives own car, public transportation)
v.
Other economic resources
(own house, savings, family support)
vi.
Economic stressors
(debts, child support, etc)
4.
Presenting Problem(s)
(include a description of the problem areas (listed separately)
from the client’s perspective, particularly noting client’s
view of their order of importance. Suggested items of focus:
a.
Were there precipitating
factors?
b.
How long have the
problems persisted?
c.
Have problems previously
occurred? What were
the circumstances?
d.
In what way, if any, do
the problems relate to each other?
5.
Relevant History
(this section will vary in comprehension according to depth and
length of treatment and in focus according to theoretical
orientation and specific nature of problems.
Suggested focus:
a.
Family and relationship
history
i.
Family of origin /
developmental issues
ii.
Past
marriages/significant relationships (duration, sexual functioning,
dissolution factors, sexual preference, etc.)
iii.
Children (from current
and prior relationships and current status)
iv.
Current family status and
structure
b.
Cultural history and
identity
i.
Issues of ethnicity and
race
ii.
Identification /
acculturation
c.
Educational history
i.
Childhood / developmental
ii.
Adulthood / current
status
d.
Vocational history
(types, stability, satisfaction, etc.)
e.
Medical history (acute /
chronic illness, hospitalizations, surgeries, major patterns of
illness in family, accidents, injuries, with whom/where/how often
receive medical care, etc.)
f.
Health practices
(sleeping, eating patterns, tobacco use, exercise, etc.)
g.
Mental health history
(prior problems, symptoms, diagnoses, evaluations, therapy
experiences, past prescribed medications, current and family of
origin mental health histories)
h.
Current medications
(dosages, purposes, physician, compliance, effects, side effects,
etc.)
i.
Legal history (arrests,
driving under the influence, jail/prison, lawsuits, any pending
legal actions)
j.
Use/abuse of alcohol or
drugs (prescription or illegal)
k.
Family (current and
origin) alcohol/drug history
6.
Interpersonal Factors
(contains a description of client’s orientation toward others in
environment)
a.
Manner of dress
b.
Physical appearance
c.
General self-presentation
d.
Nature of typical
relationship (dependent, submissive, aggressive, dominant,
withdrawing, etc.)
e.
Behavior toward therapist
(therapeutic alliance, etc.)
7.
Environmental Factors
a.
Elements in the
environment, not already mentioned, that function as stressors to
the client – those centrally related to the presenting problems
and more peripheral
b.
Elements in the
environment, not previously mentioned, that functions as support
for client (friends, family recreational activities, etc.)
8.
Personality Dynamics
a.
Cognitive factors: data
relevant to thinking and mental processes such as:
i.
Intelligence
ii.
Mental alertness
iii.
Persistence of negative
cognitions
iv.
Positive cognitions
v.
Nature and content of
fantasy life
vi.
Level of insight
(awareness of changes in feelings, behavior, reactions of others,
understanding of the interplay, etc.)
vii.
Capacity for judgment
(ability to make decisions and carry out practical affairs of
daily living)
b.
Emotional factors
i.
Typical or most common
emotional stress
ii.
Predominant mood during
interviews
iii.
Appropriateness of affect
iv.
Range of emotions client
can display
v.
Cyclical aspects of
client’s emotional life
c.
Behavioral factors
i.
Psychosomatic symptoms
ii.
Existence of problematic
habits or mannerisms
9.
Testing (both past and
present)
a.
Methods or instruments
b.
Evaluator, location,
dates, reasons for testing
c.
Results
10.
Life Transition /
Adaptation Skills
a.
Coping skills: Concrete
efforts to deal with distressing situations (for example:
anticipation, preparation, response)
b.
Social resources:
Summary of supportive social networks
c.
Psychological resources:
Adaptive personality characteristics (for example:
self-efficacy, hardiness, optimism)
11.
Formal Diagnosis
a.
DSM-IV-TR diagnosis (all
applicable axes)
b.
Checklist of
symptoms/criteria showing how client meets diagnostic criteria
12.
Therapist’s
Conceptualization of the Case
This
section contains a summary of the therapist’s view of the
problems and their effects on the client. Include only the most central and core dynamics of the client’s
personality, relationships, and environmental influences.
Note the interrelationships among the major factors.
What are the common themes?
What ties it all together?
This is a synthesis of all the relevant data and the
essence of the therapist’s understanding of the client.
13.
Treatment Plan
Based
on the above information, describe the treatment plan you will
follow to address the presenting and emerging problems.
Make it consistent with your theoretical orientation and
available empirical evidence.
Estimate the number and types of sessions needed to address
the issues.
14.
Questions
/ Issues – Note
questions you have regarding case and any issues you would like to
address.