Psychotherapy Case Formulation & Treatment Planning
Generate structured case formulations and evidence-based treatment plans from clinical data
What You Can Do
You can rapidly develop theoretically-grounded case formulations that integrate diagnostic findings, historical context, and clinical observations into a coherent narrative. The skill systematizes your conceptualization across multiple therapeutic modalities (CBT, psychodynamic, trauma-informed, systemic) and generates structured treatment plans with specific goals, interventions, and prognostic considerations—ideal for supervision presentations, case conferences, documentation, and complex diagnostic scenarios.
Features
organizes presenting problems, predisposing factors, precipitants, perpetuating factors, and protective resources into a coherent clinical narrative
generates formulations compatible with CBT, psychodynamic, trauma-informed, systemic, and integrative theoretical approaches
translates formulations into specific therapeutic goals, evidence-based interventions, and measurable outcomes
synthesizes DSM/ICD diagnostic data, comorbidity patterns, and differential diagnostic considerations into clinical reasoning
produces formulations suitable for case presentations, consultation notes, and clinical conference materials
handles multiple comorbid presentations, unclear diagnostic pictures, and treatment-resistant cases
generates accessible explanations of diagnosis and treatment rationale for non-clinical audiences
supports comprehensive assessments for legal and forensic evaluations
Example Output
Example 1: CBT-focused formulation for depression with anxiety
PRESENTING PROBLEM: 32-year-old presents with depressed mood, anhedonia, fatigue, and social withdrawal (3 months); comorbid generalized anxiety manifesting as worry, sleep disruption, and somatic tension.
CLINICAL FORMULATION: Client's depressive episode appears linked to occupational stress and perfectionist cognitions ("I must perform flawlessly or I'm a failure"). Anxiety maintains hypervigilance and avoidance of social situations, which reinforces depressive isolation. Predisposing factors include family history of mood disorder and early parental criticism. Current protective factors: stable marriage, intellectual curiosity, previous therapy experience.
TREATMENT PLAN: 16-20 sessions combining behavioral activation, cognitive restructuring of perfectionistic standards, sleep hygiene interventions, and graded social re-engagement. Target goals: return to baseline functioning within 12 weeks; reduce depressive symptoms by 50% (PHQ-9); establish daily structure and social contact.
Example 2: Trauma-informed formulation for PTSD with attachment disruption
PRESENTING PROBLEM: 28-year-old survivor of intimate partner violence (18 months post-separation) presenting with intrusive memories, hyperarousal, emotional numbing, and difficulty trusting romantic partners.
CLINICAL FORMULATION: Trauma has disrupted sense of safety and interpersonal trust. Hyperarousal and avoidance of intimacy serve protective functions but maintain isolation. Pre-trauma attachment anxiety predisposed client to tolerating boundary violations. Strengths: strong peer support network, sobriety, commitment to healing, previous resilience through other adversities.
TREATMENT PLAN: Trauma-focused CBT with emphasis on safety planning, graduated exposure, and attachment repair. 20-24 sessions. Goals: reduce PTSD symptom severity (PCL-5 score <20); increase window of tolerance; establish healthy relationship boundaries; restore self-compassion.
What's Included
- SKILL.md instruction file with complete formulation framework and clinical guidelines:
- Case formulation template with structured sections for presenting problems, predisposing/precipitating/perpetuating factors, protective factors, and diagnostic integration:
- Multi-modal conceptualization checklist supporting CBT, psychodynamic, trauma-informed, and systemic approaches:
- Treatment plan worksheet linking formulation to specific therapeutic goals, interventions, and outcome measures:
- Documentation and supervision guide for translating formulations into clinical notes, case presentations, and court-ordered reports:
Who It's For
- Licensed psychologists and clinical mental health counselors developing case formulations and treatment plans
- Therapists in supervision or consultation seeking structured formulation documentation
- Forensic psychologists and court-involved practitioners writing comprehensive evaluations
- Clinical supervisors and training directors evaluating trainee case conceptualization skills
- Psychiatrists and primary care providers integrating psychological formulation with medication management
Best For
- Initial intake assessments and comprehensive case formulation development
- Complex or comorbid presentations requiring multi-faceted conceptualization
- Treatment-resistant cases requiring formulation revisit and strategy adjustment
- Supervision presentations and case conference materials
- Forensic, court-ordered, and legal evaluations requiring detailed clinical reasoning
- Documentation for insurance authorization and treatment planning sessions with clients
You might also like
You can create comprehensive, evidence-based perioperative pain management protocols tailored to individual patient characteristics and surgical requirements. The skill assesses patient risk factors, recommends optimized multimodal analgesia regimens with specific drug selections and dosing rationales, incorporates regional techniques when appropriate, and identifies contingency plans for inadequate pain control or contraindications. This enables you to move beyond generic guidelines toward truly personalized pain management strategies that reduce opioid exposure while maintaining analgesia.
by gptomics
You can systematically analyze complex oral surgical cases by generating comprehensive pre-operative plans that consider osseous anatomy, neurovascular structures, and patient-specific risk factors. Claude structures multifactorial surgical analysis into actionable operative protocols, risk stratification reports, and detailed procedural workflows that reduce surgical time and improve clinical outcomes while providing medical-legal documentation.
by gptomics
Conduct comprehensive sports injury assessments using standardized orthopedic tests, mechanism-of-injury analysis, and functional capacity evaluation. You'll document findings in insurance-compliant formats, identify red flags requiring referral, establish objective baseline measurements for progress tracking, and generate evidence-based return-to-play recommendations with clear functional milestones.
by gptomics
This skill guides you through structured psychiatric case formulation using a biopsychosocial framework. You input patient presentation, assessment data, and clinical history, then receive a comprehensive formulation that integrates symptom synthesis, differential diagnosis reasoning, predisposing/precipitating/perpetuating factors, protective factors, and evidence-based treatment recommendations. The output is suitable for clinical documentation, insurance authorizations, case conferences, and supervision.
by gptomics
You can rapidly synthesize complex patient data—comorbidities, functional status, labs, medications—into a comprehensive risk profile and actionable optimization plan. This skill guides you through ASA classification, procedure-specific risk stratification, and patient-centered consent documentation to ensure thorough clinical reasoning and defensible preoperative assessment.
by gptomics
You'll develop comprehensive, hierarchical differential diagnoses that integrate clinical reasoning principles with patient safety. This framework helps you identify 'can't-miss' diagnoses, challenge diagnostic assumptions, and sequence diagnostic workup logically—whether managing complex presentations, atypical symptoms, or high-stakes clinical decisions in primary care, urgent care, or specialty settings.
by gptomics
You can convert clinical observation notes, standardized assessment results (FIM, COPM, AMPAC, etc.), and patient history into professionally formatted occupational therapy functional assessment reports. The skill synthesizes raw data into cohesive narratives that document baseline function, identify specific functional limitations, justify interventions to insurance companies, and establish measurable treatment goals—reducing hours of manual documentation while ensuring compliance with insurance requirements and clinical standards.
by gptomics
This skill transforms fragmented OT assessment findings—ROM measurements, strength tests, ADL observations—into cohesive clinical narratives that connect impairment to functional limitation to participation restriction. You'll generate SMART goals that satisfy both clinical rigor and insurance reimbursement standards, and build intervention plans with explicit evidence-based rationale that accelerates authorization and justifies medical necessity to payers.
by gptomics