Clinical Thinking Tools · Document 2 of 3
Clinical Formulation Worksheet
From information to understanding, building the clinical story
This is a thinking tool, not a documentation form. Use it in supervision or between sessions to build your formulation as a working hypothesis. Your goal here is not certainty. It's a coherent, useful story about what's happening and what it means for treatment. Expect to revise it.
If you trained with predisposing, precipitating, perpetuating, and protective factors, this will feel familiar. Roots, Gaps, Restraints, and Resources are doing the same job in the plainer language this series uses throughout, and each section below names the bridge so nothing gets lost in translation.
Presenting Concern: Your Anchor
What brought this person here, and why now? Hold this in front of you as you move through every category below. A factor only matters here if it helps explain this presentation, for this person, at this point in time.
Where This Case Pulled You First
Roots, Gaps, Restraints, and Resources connect back to the presenting concern and to each other. There is no required order. Work in whatever direction this case pulls you, then loop back to fill in the rest. This does not require a settled theoretical orientation. The pull itself is useful information.
Goals
Treatment direction
What is this client working toward, and what does that tell you?
What is the client working toward in their own terms? Write it in their language, not yours.
What might this goal mean beneath the surface, beyond what's been stated?
Roots
Predisposing factors
What was already shaping this person's experience, before this concern emerged?
What developmental, relational, or historical experiences are most relevant to the current picture?
What system-level factors, such as family, community, cultural, structural, or institutional, are part of this story?
Consider biological, psychological, and social roots together rather than separately. A family psychiatric history, an early attachment pattern, and a history of marginalization can all be doing related work in the same presentation.
Positionality check: Whose knowledge and framework is centered in your understanding of this person's roots? What might your own vantage point make harder to see?
Gaps
Precipitating factors
What brought this concern to the surface now, and how is it showing up?
What has changed or escalated that brought this person to treatment now, at this moment? It is not always the most dramatic thing in the history.
How is distress showing up across domains? Consider safety, basic needs, and relationships.
What does the gap between where they are and where they want to be suggest about what treatment needs to address first?
Restraints
Perpetuating / maintaining factors
What is making this hard to move through right now?
What patterns, whether behavioral, cognitive, relational, or physiological, are maintaining the problem? Coping strategies that once served a real purpose can still be part of the answer.
How much of what's maintaining this is individual, relational, or structural? Does that proportion matter for treatment?
This is often the most clinically generative category and the one that gets the least attention. What is sustaining the difficulty usually points toward where the work needs to happen.
Given what's maintaining this, where does intervention most need to land?
Resources
Protective factors
What strengths and capacities are already present to build from?
What has helped this person survive and adapt, even when those strategies have costs?
What strengths, relationships, and community resources are available to this client?
Resilience is not a trait someone has or lacks. It is a function of what someone has access to. This category changes the formulation. It does not just close it out.
Synthesis
Building the clinical story from its parts
Best current formulation narrative
Fill these in whatever order matches how you actually worked through the case. Left to right is a reading order for the narrative below, not a required sequence for building it.
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Reference grid: biopsychosocial examples by category
Category
Biological
Psychological
Social
Roots
Family psychiatric history, chronic health conditions, neurodevelopmental differences
Early attachment patterns, temperament, prior trauma exposure
Cultural background, marginalization history, family of origin dynamics
Gaps
Health scare, sleep disruption, medication change
A loss, a shift in self-concept, an accumulation that tipped
Job loss, relationship rupture, housing change, system involvement
Restraints
Chronic illness, sleep or substance patterns, unmanaged symptoms
Cognitive patterns, avoidance, coping strategies that once served a purpose
Relational dynamics that repeat, structural barriers, lack of access
Resources
Physical health, capacity for rest and regulation
Reflective capacity, insight, prior positive treatment experience
Relational support, community, cultural and spiritual connection