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Cultural Formulation Interview (CFI)
Cultural Formulation Interview (CFI)
Supplementary modules used to expand each CFI subtopic are noted in parentheses.
Name: Sabrina Hinajosa
Age: 29
GUIDE TO INTERVIEWER
Sex: Female
Date: Today
INSTRUCTIONS TO THE INTERVIEWER ARE ITALICIZED.
The following questions aim to clarify key aspects of the INTRODUCTION FOR THE INDIVIDUAL:
presenting clinical problem from the point of view of
I would like to understand the problems that bring you here so that I can
the individual and other members of the individual’s
help you more effectively. I want to know about your experience and
social network (i.e., family, friends, or others involved
ideas. I will ask some questions about what is going on and how you
in current problem). This includes the problem’s
are dealing with it. Please remember there are no right or wrong
meaning, potential sources of help, and expectations
answers.
for services.
CULTURAL DEFINITION OF THE PROBLEM
CULTURAL DEFINITION OF THE PROBLEM
(Explanatory Model, Level of Functioning)
Elicit the individual’s view of core problems and key
concerns.
Focus on the individual’s own way of understanding the
problem.
Use the term, expression, or brief description elicited in
question 1 to identify the problem in subsequent
questions (e.g., “your conflict with your son”).
1. What brings you here today?
IF INDIVIDUAL GIVES FEW DETAILS OR ONLY MENTIONS
SYMPTOMS OR A MEDICAL DIAGNOSIS, PROBE:
Ask how individual frames the problem for members of
the social network.
2. Sometimes people have different ways of describing their problem to
their family, friends, or others in their community. How would you
describe your problem to them?
People often understand their problems in their own way, which may
be similar to or different from how doctors describe the problem. How
would you describe your problem?
I recently lost my mother-in-law to a heart attack in the process
of evacuating from the hurricane. She was my rock. I was
closer to her than my own mother. I am feeling completely
overwhelmed and emotionally exhausted from everything
we’ve been through in the past month, and I am just so sad
and angry all the time.
That I am a crappy daughter-in-law who didn’t see the signs and
respond fast enough and that I was more concerned about my
house being okay than supporting her.
Focus on the aspects of the problem that matter most to 3. What troubles you most about your problem?
the individual.
That I can’t get her back.
CULTURAL PERCEPTIONS OF CAUSE, CONTEXT, AND SUPPORT
CAUSES
(Explanatory Model, Social Network, Older Adults)
This question indicates the meaning of the condition for
the individual, which may be relevant for clinical care.
4. Why do you think this is happening to you? What do you think are the
causes of your [PROBLEM]?
I know rationally that there was nothing that could really be
done, but I have a lot of self-blame. If I hadn’t have left her
Page 1 of 5
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Cultural Formulation Interview (CFI)
home alone to go seal up my home and get my kids maybe
she’d be here still. And, of course, there is the stupid
hurricane.
Note that individuals may identify multiple causes,
depending on the facet of the problem they are
considering.
Focus on the views of members of the individual’s social
network. These may be diverse and vary from the
individual’s.
PROMPT FURTHER IF REQUIRED:
Some people may explain their problem as the result of bad things
that happen in their life, problems with others, a physical illness, a
spiritual reason, or many other causes.
5. What do others in your family, your friends, or others in your
community think is causing your [PROBLEM]?
Everyone says it was “just her time”. Even my husband. He
thinks this was all God’s plan, including the hurricane. That just
makes me thing God’s a jerk. Mostly everyone feels bad for us
and says it was all just an unfortunate series of events. I know
this is true but it is so infuriating to hear right now. I can’t
handle it.
STRESSORS AND SUPPORTS
(Social Network, Caregivers, Psychosocial Stressors, Religion and Spirituality, Immigrants and Refugees, Cultural Identity, Older
Adults, Coping and Help Seeking)
Elicit information on the individual’s life context, focusing
on resources, social supports, and resilience. May
also probe other supports (e.g., from co-workers, from
participation in religion or spirituality).
6. Are there any kinds of support that make your [PROBLEM] better,
such as support from family, friends, or others?
Focus on stressful aspects of the individual’s
environment. Can also probe, e.g., relationship
problems, difficulties at work or school, or
discrimination.
7. Are there any kinds of stresses that make your [PROBLEM] worse,
such as difficulties with money, or family problems?
My kids are my main focus right now. They are just getting
back to school and have lost their abuela. I want them to be
okay. Being with them reminds me of her and makes me feel
better.
Yes, our house is still a wreck. We are back in there, but we
haven’t been able to get flooring replaced and there is a ton of
water damage. We didn’t have flood insurance and the house
insurance doesn’t cover it. I have no idea how we are going to
manage it all. Not to mention we just had to pay for my motherin-law’s funeral. Our friends and family are trying to help, but it’s
just a lot. Just thinking about it all makes me want to shut down.
ROLE OF CULTURAL IDENTITY
(Cultural Identity, Psychosocial Stressors, Religion and Spirituality, Immigrants and Refugees, Older Adults, Children and
Adolescents)
Sometimes, aspects of people’s background or identity can make
their [PROBLEM] better or worse. By background or identity, I
mean, for example, the communities you belong to, the languages
you speak, where you or your family are from, your race or ethnic
background, your gender or sexual orientation, or your faith or
religion.
Ask the individual to reflect on the most salient elements 8. For you, what are the most important aspects of your background or
of his or her cultural identity. Use this information to
identity?
tailor questions 9–10 as needed.
Page 2 of 5
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This material can be reproduced without permission by researchers and by clinicians for use with their patients.
Cultural Formulation Interview (CFI)
My husband is Mexican and we are very close to his family. They
are all very tight-knit and love to celebrate everything all the
time. They “adopted” me into their family when we started
dating 12 years ago, and I’ve been one of them since. I would
say that is my primary support network.
My husband is Catholic, but he doesn’t practice actively and I
never converted. I was never much of anything growing up. My
parents divorced when I was young and neither of them were
very spiritual. I think my mom sort of believed in Buddhist
principles but my dad was agnostic. Before Maria died, my
husband and I were talking about how to raise our kids in faith
since they are getting older, but I’m really struggling with the
whole concept of God right now.
Elicit aspects of identity that make the problem better or 9. Are there any aspects of your background or identity that make a
worse.
difference to your [PROBLEM]?
Probe as needed (e.g., clinical worsening as a result of
It’s great to have a family who is so supportive and so close by.
discrimination due to migration status, race/ethnicity,
But Maria was the heart of the family. We are all lost without her
or sexual orientation).
and I don’t know how things will change without her here to
keep us all together. I have a ton of fear around that.
Probe as needed (e.g., migration-related problems;
10. Are there any aspects of your background or identity that are causing
conflict across generations or due to gender roles).
other concerns or difficulties for you?
Maybe just my current anger at God. My husband really seeks
comfort in prayer right now and it just ticks me off. We’ve
fought about it a couple of times.
CULTURAL FACTORS AFFECTING SELF-COPING AND PAST HELP SEEKING
SELF-COPING
(Coping and Help Seeking, Religion and Spirituality, Older Adults, Caregivers, Psychosocial Stressors)
Clarify self-coping for the problem.
11. Sometimes people have various ways of dealing with problems like
[PROBLEM]. What have you done on your own to cope with your
[PROBLEM]?
I’m here. I’m tired of crying and yelling all the time. I know
something needs to change, so I’m here. Outside of that I don’t
really do anything. I’m not a drinker, and I don’t really like to
exercise. There just hasn’t really been time for TV or reading,
and I don’t think I could focus on those anyway. Mostly I’ve just
thrown myself into taking care of my kids and trying to shield
them from everything.
PAST HELP SEEKING
(Coping and Help Seeking, Religion and Spirituality, Older Adults, Caregivers, Psychosocial Stressors, Immigrants and Refugees,
Social Network, Clinician-Patient Relationship)
Page 3 of 5
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Cultural Formulation Interview (CFI)
Elicit various sources of help (e.g., medical care, mental 12. Often, people look for help from many different sources, including
health treatment, support groups, work-based
different kinds of doctors, helpers, or healers. In the past, what kinds
counseling, folk healing, religious or spiritual
of treatment, help, advice, or healing have you sought for your
counseling, other forms of traditional or alternative
[PROBLEM]?
healing).
PROBE IF DOES NOT DESCRIBE USEFULNESS OF HELP
Probe as needed (e.g., “What other sources of help
RECEIVED:
have you used?”).
I haven’t sought help for this. I mean, I’ve talked to some friends
Clarify the individual’s experience and regard for
and family. They are the ones who recommended I come in, but
previous help.
nothing else really. I did come to counseling one other time in
the past. I was raped five years ago while on a business trip. It
turned my world upside down, and I ended up getting some
help. I had to. It’s not the same thing, but I feel that same sense
of being out of my own control now.
What types of help or treatment were most useful? Not useful?
The counseling was helpful at the time. I’m not sure I would
have made it without it. I thought I was losing my mind and no
ability to trust anyone, even my own husband. Of course, my
mother in law helped a lot too. She always protected me like a
daughter and made sure I was okay through that experience.
BARRIERS
(Coping and Help Seeking, Religion and Spirituality, Older Adults, Psychosocial Stressors, Immigrants and Refugees, Social
Network, Clinician-Patient Relationship)
Clarify the role of social barriers to help seeking, access
to care, and problems engaging in previous treatment.
Probe details as needed (e.g., “What got in the way?”).
13. Has anything prevented you from getting the help you need?
PROBE AS NEEDED:
For example, money, work or family commitments, stigma or
discrimination, or lack of services that understand your language
or background?
Time is the real issue. I don’t really have time for things like
this with everything else going on. And, of course there is
money. My husband says it is worth it, and I know I need it,
but I hate to think I am costing us any more money when we
need basic things like carpet in our house.
CULTURAL FACTORS AFFECTING CURRENT HELP SEEKING
PREFERENCES
(Social Network, Caregivers, Religion and Spirituality, Older Adults, Coping and Help Seeking)
Clarify individual’s current perceived needs and
Now let’s talk some more about the help you need.
expectations of help, broadly defined.
14. What kinds of help do you think would be most useful to you at this
Probe if individual lists only one source of help (e.g.,
time for your [PROBLEM]?
“What other kinds of help would be useful to you at this
I wish I could turn back time and make it so this never
time?”).
happened. I know I can’t do that, but that is what I wish. Outside
of that I just want to get through this, be able to take care of my
kids, have a safe home to live in, not be so moody, and figure
out how to survive without Maria.
Focus on the views of the social network regarding help 15. Are there other kinds of help that your family, friends, or other people
seeking.
have suggested would be helpful for you now?
Page 4 of 5
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Cultural Formulation Interview (CFI)
No. I mean my husband wishes I would consider prayer or God.
He keeps telling me that was important to his mom, and I know it
was. But I can’t go there right now. Everyone else says I just
need to give myself time, but I don’t even know what that means.
CLINICIAN-PATIENT RELATIONSHIP
(Clinician-Patient Relationship, Older Adults)
Elicit possible concerns about the clinic or the clinicianpatient relationship, including perceived racism,
language barriers, or cultural differences that may
undermine goodwill, communication, or care delivery.
Probe details as needed (e.g., “In what way?”).
Address possible barriers to care or concerns about the
clinic and the clinician-patient relationship raised
previously.
Sometimes doctors and patients misunderstand each other because
they come from different backgrounds or have different expectations.
16. Have you been concerned about this and is there anything that we
can do to provide you with the care you need?
I don’t know. It all seems so arbitrary at this point. I mean my
last counseling experience was good. I don’t think I would
have survived without going. But I also went because I had a
lot of support, especially from Maria. Without her this all feels
somewhat pointless. I’m willing to come because I know I need
the help and I know my girls need their mom to be okay. I
guess I just need you not to ask me to pray or tell me it’s not
my fault. I’m so tired of all of that. My last counselor was really
good at holding me accountable, so I guess that’s good too. I
need that. This is also the first time I’m seeing a male
counselor. I don’t really worry about that too much, but I’m not
exactly used to that and don’t really know what to expect of it
either. I’m rambling…I don’t really know.
Page 5 of 5
Copyright © 2013 American Psychiatric Association. All Rights Reserved.
This material can be reproduced without permission by researchers and by clinicians for use with their patients.
COLUMBIA-SUICIDE SEVERITY RATING SCALE
Screen Version
SUICIDE IDEATION DEFINITIONS AND PROMPTS
Past month
Sabrina
Ask questions that are bolded and underlined.
YES
NO
Ask Questions 1 and 2
1) Wish to be Dead:
Person endorses thoughts about a wish to be dead or not alive
anymore, or wish to fall asleep and not wake up.
X
Have you wished you were dead or wished you could go to
sleep and not wake up?
2) Suicidal Thoughts:
General non-specific thoughts of wanting to end one’s life/commit
suicide, “I’ve thought about killing myself” without general
thoughts of ways to kill oneself/associated methods, intent, or
plan.
X
Have you actually had any thoughts of killing yourself?
If YES to 2, ask questions 3, 4, 5, and 6. If NO to 2, go directly to question 6.
3) Suicidal Thoughts with Method (without Specific Plan or
Intent to Act):
Person endorses thoughts of suicide and has thought of a least
one method during the assessment period. This is different than a
specific plan with time, place or method details worked out. “I
thought about taking an overdose but I never made a specific plan
as to when where or how I would actually do it…and I would never
go through with it.”
X
4) Suicidal Intent (without Specific Plan):
Active suicidal thoughts of killing oneself and patient reports
having some intent to act on such thoughts, as opposed to, “I
have the thoughts but I definitely will not do anything about
them.”
X
Have you been thinking about how you might kill yourself?
Have you had these thoughts and had some intention of
acting on them?
For inquiries and training information contact: Kelly Posner, Ph.D.
New York State Psychiatric Institute, 1051 Riverside Drive, New York, New York, 10032;
posnerk@nyspi.columbia.edu
© 2008 The Research Foundation for Mental Hygiene, Inc.
SUICIDE IDEATION DEFINITIONS AND PROMPTS
Past month
Sabrina
Ask questions that are bolded and underlined.
YES
5) Suicide Intent with Specific Plan:
Thoughts of killing oneself with details of plan fully or partially
worked out and person has some intent to carry it out.
X
Have you started to work out or worked out the details of
how to kill yourself? Do you intend to carry out this plan?
6) Suicide Behavior Question:
X
Examples: Collected pills, obtained a gun, gave away valuables,
wrote a will or suicide note, took out pills but didn’t swallow any,
held a gun but changed your mind or it was grabbed from your
hand, went to the roof but didn’t jump; or actually took pills, tried
to shoot yourself, cut yourself, tried to hang yourself, etc.
I went to a
nearby
bridge and
was going to
jump but
changed by
mind
Have you ever done anything, started to do anything, or
prepared to do anything to end your life?
If YES, ask: How long ago did you do any of these?
Over a year ago? Between three months and a year ago? Within
the last three months?
NO
5 years ago
For inquiries and training information contact: Kelly Posner, Ph.D.
New York State Psychiatric Institute, 1051 Riverside Drive, New York, New York, 10032;
posnerk@nyspi.columbia.edu
© 2008 The Research Foundation for Mental Hygiene, Inc.
COU 680 Adult Psychosocial Assessment Sabrina
Date of appointment: Today
Time of appointment: 5:00 pm
Client Name: Sabrina Hinajosa
Age: 29
DOB: 3/23/89
Gender:  Male  Female  Transgender
Preferred Name/Nickname: N/A
Ethnicity: ï‚£ Hispanic
Race: Caucasian
 Non‐Hispanic
Current Marital/Relationship Status:  Single  Married  Divorced  Widowed  Domestic Partnership
Name of Person completing form: Sabrina
Relationship to client: Self
PRESENTING PROBLEM (Briefly describe the issues/problems which led to your decision to seek therapy services):
I recently lost my mother-in-law to a sudden heart attack immediately prior to the recent hurricane. Within a matter
of a single day I lost the mother figure in my life, was evacuated from my home, and had a hurricane destroy parts
of my house. I’m completely overwhelmed, sad, and angry at the world.
How severe, on a scale of 1‐10 (with 1 being the most severe), do you rate your presenting problems?
MOST SEVERE
1
2
3
4
5
6
7
8
9
10
LEAST SEVERE
PRESENTING PROBLEM CATEGORIZATION: (Please check all the apply and circle the description of symptom)
Symptoms causing concern, distress or impairment:
ï‚£ Change in sleep patterns (please circle): sleeping more
ï‚£ Concentration:
sleeping less
difficulty falling asleep
difficulty staying asleep
difficulty waking up
difficulty staying awake
Decreased concentration
Increased or excessive concentration
ï‚£ Change in appetite: Increased appetite
Decreased appetite
ï‚£ Increased Anxiety (describe): I have a lot of fear of the unknown. Everything feels out of my control.
 Mood Swings (describe): I’m irritable all of the time. I go back and forth between extreme bouts of sadness
and complete anger and rage at the situation. The only place I feel calm is with my kids
and only because I really focus on making sure they are ok.
ï‚£ Behavioral Problems/Changes (describe): I struggle to stay focused on anything other than taking care of
my kids. I feel aimless and purposeless and have stopped putting forth much effort at work or in our home.
Everything just seems both overwhelming and pointless.
ï‚£ Victimization (please circle): Physical abuse Sexual abuse
Robbery victim
Human trafficking
Assault victim
Dating violence
DUI/DWI crash
Elder abuse
Domestic Violence
Survivors of homicide victims
Other:
1
Adult molested as child
Other (Please describe other concerns):
How long has this problem been causing you distress? (please circle)
One week
One month
1 – 6 Months
6 Months – 1 Year
Longer than one year
How do you rate your current level of coping on a scale of 1 – 10 (with 1 being unable to cope)?
UNABLE TO COPE
1
2
3
4
5
6
7
8
9
10
ABLE TO COPE
EMPLOYMENT:
Currently Employed?  Yes  No
If employed, what is your occupation? Bank teller
Where are you working? XYZ Bank
How long? 3
Days/Months/Years
Do you enjoy your current job?  Yes  No
What do you like/dislike about your job? I used to really
like my job. I really like the people I work with and it offers a lot of good interaction with people in the nearby
community. I’m typically a really outgoing person that people like, so this has been a good fit for me. Right now
though, I don’t really get anything out of it other than knowing I need the job because we need the money. It’s
like I go in and do what I have to do until I leave. My focus has been lacking and it is showing.
If you are not currently employed, how long has it been since you last worked?
Months/Years
What was your occupation before becoming unemployed?
What led to becoming un‐employed?
PSYCHIATRIC/PSYCHOLOGICAL HISTORY:
Are you currently being seen by a psychiatrist?  Yes  No
If yes, name of current psychiatrist
Length of Treatment
Have you ever been diagnosed with a mental health, emotional or psychological condition?
Yes  No
If yes, what diagnosis were you given? Post-Traumatic Stress Disorder
When? 5 years ago
By Whom? Dr. Mental Health
2
Previous counseling/hospitalizations for mental health/drug and alcohol concerns
Dates of Service
Place/Provider
January 2013-August JKL Counseling and
2013
Wellness Center
Reason for treatment
Rape Trauma
Were the services helpful?
Yes
SAFETY CONCERNS:
Are you presently suicidal?  Yes No
If Yes, please explain
Have you ever attempted to commit suicide?  Yes  No
If yes, when and how? Well, I didn’t fully attempt. I
had plans to jump off the bridge near my house, but ultimately changed my mind.
Is there a history of suicide in your immediate and/or extended family?  Yes  No My father committed suicide
when I was 13 years old.
Are you presently homicidal?  Yes  No
If Yes, please explain
Additional Information: (please add additional information as needed to address past and current safety issues): I’m
not actively suicidal, but I am aware that my last experience got me really close. I don’t feel as out of control right now
as I did then, but I have some small fear that those feelings of chaos and rage are resurfacing and I won’t be able to
control them on my own.
3
FAMILY MENTAL HEALTH HISTORY
Please identify if any members of your family have had a history of any of the following mental health/drug
abuse/legal concerns.
Family History
Depression
Self
Anxiety
Bipolar
Disorder
Schizophrenia
ADHD/ADD
X
Trauma
History
Alcohol
Abuse
Drug
Abuse
X
X
X
Incarceration
X
Mother
X
Father
Abusive
Behavior
X
X
X
Sister
Brother
Maternal
Uncle
Paternal
Uncle
Maternal
Aunt
Paternal
Aunt
Maternal
Grandmother
Paternal
Grandmother
Maternal
Grandfather
Paternal
Grandfather
Biological
Child
X
X
X
X
X
X
X
X
X
X
X
X
RELATIONSHIP/MARITAL STATUS
Current Marital/Relationship Status:  Single Married
 Live‐In Partner
ï‚£ Divorced
ï‚£ Widowed
ï‚£ Significant Other (Not Living Together)
If applicable, list divorces and separations:
How do you identify yourself:  Heterosexual  Homosexual  Bisexual
ï‚£ Questioning
What do you think is important for us to know about your significant relationships – current & past? My parents
divorced when I was about 3 years old and I lived largely with my mom although I saw my dad every couple of weeks.
My dad was always “fun” but really irresponsible. I remember that even as a kid. He got in trouble a lot and spent some
time in jail for stealing a car. He just didn’t seem to ever take responsibility for anything. His bipolar disorder only
complicated that experience. He went from the highest of highs to the lowest of lows and ultimately ended up shooting
4
himself one night, alone in his apartment. My mom was a bit of a “hippie”. She came from a highly abusive and
controlling family, so she decided to take the opposite approach with me. She was, on occasion, physically abusive to
me, but mostly she just moved in and out of the world high on drugs and full of “free love”. I lived a nomadic existence
with her and I often felt like the parent to my parents. I met my husband Tony in high school. We started dating and I
immediately fell in love with him and his family. They welcomed me in for meals and made life feel “stable”. His
mom, Maria, was like the mom I always wanted, and she often said I was the daughter she wished she had. We were
very close, and I loved her very much. I have two daughters of my own (6 and 8), and they are the center of my
universe.
5
FAMILY COMPOSITION
Spouse/Significant Other’s Name: Tony Hinajosa
Employed Currently: Yes  No
Age: 30
Living with client  Not living with client
If Yes, place of employment: BIG House Construction
Occupation: General Contractor
Please list the names, ages, relationships and other relevant information regarding all immediate family members
whether living in‐ or outside the home. Please include all members currently residing in YOUR household.
Name
Gender
Relationship To
Client
Age
Living With Client
Yes
Tony Hinajosa
Male
30
Spouse
Lyla Hinajosa
Female
8
Child
Yes
Amelia Hinajosa
Female
6
Child
Yes
Henry Hinajosa
Male
58
Father-in-law
No
Meg Wick
Female
56
Mother
No
What else do you feel/believe would be helpful, or important for us to know/understand about your
relationships with your family or about your family members?
I don’t have regular contact with my mom. She lives about three hours away and we only really see each other around
Christmas and out of a sense of obligation—mostly for my kids. She doesn’t really put in any effort and I don’t either.
RECENT LOSSES:
Family Member  Friend  Health  Lifestyle  Job
Who?
Mother-in-law
When?
ï‚£ Income
1-month ago
ï‚£ Housing
ï‚£ None
Nature of Loss? Heart attack
Other Losses: father—suicide when I was 13; all my grandparents are also deceased
HOUSING:
Would you consider your housing to be:  stable unstable
Do you currently:
Own  Rent  Live with relatives/friends (temporary)  Emergency Shelter
ï‚£ Live with relatives/friends (permanent)
ï‚£ Homeless
6
 Transitional Housing
How long have you lived in your current living situation? 6 years
How often have you moved in the past two years? N/A
What else do you think is important for us to understand about your housing/living situation?
We currently live at home but our house was flooded with the hurricane, so it needs pretty extensive repair.
Typically, we would stay with my in-laws, but with my mother-in-law’s death there have been a lot of family visiting,
and we don’t want to overburden Henry. I also don’t think I could handle being there without her. Just the thought of
that house makes me cry. Really any reminder of her does, but that is particularly hard for me. Our home is functional,
but we are without carpet and the paint is peeling off. My husband is in construction, so I know we will get it fixed
eventually, but it is chaotic and we don’t have the insurance money to pay for anything right now.
FOSTER CARE INVOLVEMENT
Have you ever been in foster care?  Yes  No
Reason: ï‚£ Familial Placement
From
age to
age
 Non‐Familial Placement
HEALTH HISTORY
How would you describe your overall health? Generally good
Do you have any health issues?  Yes  No
If Yes, please list below.
Do you have any recurrent medical conditions such as allergies or asthma?  Yes  No
If yes, please list:
Please list below current medical problems, physical limitations, sleep problems, unusual eating habits, poor hygiene,
overall physical fitness, head injuries, early childhood infections, eating disorders, knee or back injuries, asthma, etc.
Medical Conditions
Are you currently
receiving
treatment?
High blood pressure
Yes
Insomnia
No
Lack of appetite
No
Provider
Dr. Medicine
7
Does this condition
cause stress or
What have you found
impairment at this
that helps?
time?
Yes-I need to be more I just need to stay on my
consistent on my
medication as prescribed
medication which
stresses me out but the
stress I am under leads
me to forget
Yes-I find it very hard Nothing
to go to sleep or stay
asleep
Yes, but only because Trying to eat when my
I know I should be
kids eat
Do you currently take any medications?  Yes  No
Please list medications (including psychotropic, over‐the‐counter, herbal remedies) that you have taken in the
past 6 months.
Medication
Diuril
Dosage
500mg
Frequency
2x/day
Reason for
Medication
Prescribed By
Dr. Medicine
High Blood Pressure
Are you taking the medications as prescribed?  Yes  No
If No, please explain: I have trouble remembering to
take it consistently. I usually remember at least one dose per day, but with all that is going on, I frequently forget.
Symptoms start fairly quickly and then I get angry at myself and this whole situation.
Additional information (if needed):
Have you ever had a serious accident/illness or hospitalization?  Yes  No
Please list all past hospitalizations, surgeries, accidents, or illnesses in the chart below.
Reason for Previous Hospitalizations, Accident, Illness
Date/Location of Hospitalization
Traumatic rape
December 2012/General Hospital
Childbirth
July 2012/Local Hospital
Childbirth
June 2010/Local Hospital
Car wreck
November 2006/City Hospital
8
Primary Care Doctor: Dr. Medicine
Medicine Family Practice Phone Number: 000-123-9876
Facility:
ALCOHOL/DRUG ASSESSMENT:
Current or past history of alcohol/drug use?  Yes  No
to next section.
If Yes, complete table below. If no history, move
Do you ever drink or use more than you intend to?  Yes  No If yes, how often:  Almost every time
ï‚£ Occasionally ï‚£ Seldom ï‚£ More often lately
ï‚£ When under stress ï‚£ Other:

Have you ever had to increase the amount of alcohol/drug you consume to get the same effect?
Yes  No If Yes, when did you first notice this change? I don’t currently drink but did in my early twenties.
I also drank quite a bit after my rape experience and this is when it escalated
Do you have a history of overdosing on alcohol/drugs?  Yes  No If yes, when was the last OD?
Have you ever experienced a black out?  Yes  No If Yes, how often:  Almost every time
 Occasionally  Seldom  More often lately
ï‚£ When under stress ï‚£ Other:

Do you have a history of seizures while under the influence?  Yes  No
With whom do you typically consume alcohol?  Friends  Family  N/A‐Alone  Strangers  Other
Have you ever experienced problems related to your alcohol use?  Yes  No
 Legal  Social/Peer  Work  Family  Friends  Financial
If yes, please describe: When I was drinking after the rape, I did so to excess. It caused a lot of problems for me
at home and work. I quit drinking as part of my therapy process and have been sober since.
If yes, have you continued to drink/use drugs?  Yes  No
LEGAL INVOLVEMENT:
Please indicate by checking below your legal status.
No Involvement
ï‚£ Probation | Length:
ï‚£ Parole | Length:
ï‚£ Charges Pending
Charges:
ï‚£ Prior Incarceration
 Law Suit or other Court Proceeding
Probation/Parole Officer’s Name:
Contact #:
Additional Information:
HISTORY OF ABUSE/NEGLECT:
Have you ever been abused or assaulted?  Yes  No
If Yes, please complete the chart below.
9
Type of Abuse
ï‚£ Sexual
Physical
Emotional
Verbal
Abandoned/Neglected
By Whom?
At What Age?
Mother
childhood
Mother
childhood
Mother
childhood
Mother and Father
childhood
Was it Reported?
ï‚£ Yes ï‚£ No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
Do you feel like you are in danger now?  Yes No
What else do you feel is important for us to know?
I don’t see my mother as a bad person. She’s more the product of how she was raised. I knew she loved me and I know
my dad did too. They were just “kids” playing the role of parents. I love my mother as person and hate what she has
gone through in her own life. We just won’t ever be close.
HISTORY OF VIOLENCE:
Have you ever been accused of abusing or assaulting someone?  Yes  No If yes, please complete chart below.
Type of Abuse
ï‚£ Sexual
ï‚£ Physical
ï‚£ Emotional
ï‚£ Verbal
ï‚£ Abandoned/Neglected
To Whom?
At What Age?
Was it Reported?
ï‚£ Yes ï‚£ No
ï‚£ Yes ï‚£ No
ï‚£ Yes ï‚£ No
ï‚£ Yes ï‚£ No
ï‚£ Yes ï‚£ No
What else do you feel/believe is important for us to know?
STRENGTHS/RESOURCES/SUPPORTS:
What limitations do you have (if any)? Financial, no “mom” to make things okay
What strengths do you have? My kids. I’m a good mom and I love my kids more than anything. I’m a generally good
person who people like to be around.
What resources do you have to help with your current problem?
My husband and his family, friends
What experiences (past & present) will help you in improving the current situation?
I know I made it through something devastating before so I can again. I know counseling helped. I know I need to seek
help from others who care. It’s just hard. There are days I think this is just too much, and I will never make it through.
What are you (and your family) already doing to improve the current situation?
I’m coming to counseling. My husband is working on getting our house repaired.
10
Who can you count on for support? ï‚£ Parents
ï‚£ Boyfriend/Girlfriend ï‚£ Siblings ï‚£ Pastor
Extended Family Friends Neighbors
ï‚£ School Staff ï‚£ Church ï‚£ Group
 Community Services  Doctor  Other: Co-workers
CURRENT NEEDS/GOALS
What do you feel is your biggest need right now? Coping with Maria’s loss
What do you most hope to gain from coming to counseling? Staying afloat, being a focused and worthwhile person
again.
If you were to pick three goals to work on, what would they be?
Goal 1: Working through the loss of Maria
Goal 2: Finding stability in our home life
Goal 3: Improving my outlook on life so I can plug back in at home and at work
What else would you like for us to be aware of?
I was significantly impacted by my prior rape experience. I have worked hard to overcome it, but it was a violent
and emotionally, mentally, and physically devastating experience for me.
INDIVIDUAL COMPLETING ASSESSMENT
Printed Name Sabrina Hinajosa
Date: Today
Signature Sabrina Hinajosa
11
COU 680 Final Project Two Guidelines and Rubric
Overview
The first final project for this course is the creation of a trauma toolbox ePortfolio consisting of resources selected from counseling literature that you will use to
support clients who are experiencing symptoms of crisis and trauma. After you submit your first final project, you will use the trauma toolbox to help inform
your second final project, a case conceptualization. Both of these will be due in Week Nine.
In this assignment, you will demonstrate your mastery of the following course outcomes:
ï‚·
ï‚·
ï‚·
COU-680-01: Assess the various types of crises and trauma and their corresponding symptomatology to inform case conceptualization
COU-680-02: Evaluate the factors that contribute to experiences of crisis and trauma in clients to inform treatment approaches
COU-680-04: Evaluate trauma-informed treatment approaches and interventions for a variety of crisis situations to inform a counseling session
Prompt
Use the Final Project Case Study Sabrina file and your trauma toolbox to address the headers below. Use the headers as a template to organize your case
conceptualization.
Case Conceptualization Headers
I.
Describe the presenting concerns the client is experiencing. [COU-680-01]
A. What does the client typically experience and demonstrate when the presenting problem, issue, or challenge is activated?
II.
Describe the current triggers that activate the client’s presenting problem. [COU-680-01]
A. Describe the triggers (people, places, things, and sensory experiences) that activate the behavioral, cognitive, emotional, and physiological
patterns that result in the client’s presenting problem, issue, or challenge.
III.
Identify any maladaptive patterns the client is experiencing. [COU-680-01]
A. Explain the inflexible and/or ineffective manner the client is feeling (i.e., emotions) in reaction to the current triggers and the presenting
concerns.
B. Explain the inflexible and/or ineffective manner the client is thinking (i.e., cognitions) in reaction the current triggers and the presenting
concerns.
C. Explain the inflexible and/or ineffective manner the client is behaving (i.e., actions) in reaction to the current triggers and the presenting
concerns.
1
D. Explain the inflexible and/or ineffective manner the client is experiencing (i.e., physiology) the current triggers and the presenting concerns
IV.
Identify any developmental influences the client is experiencing. [COU-680-02]
A. What are the developmental factors (occurred in the past) that promote the client’s adaptive and maladaptive functioning patterns?
V.
Describe biological concerns the client is experiencing. [COU-680-02]
A. Describe the biological, neurological, physiological issues or prior diagnoses.
VI.
Describe the promoters the client is experiencing. [COU-680-02]
A. What are the client’s present experiences (onset to present) that influence the maintenance of the presenting concerns?
B. What are the client’s strengths?
VII.
Describe the client’s cultural identity. [COU-680-02]
A. Summarize how the client’s cultural identity has influenced her development.
VIII.
Identify any cultural stressors that may be influencing the client. [COU-680-02]
A. Summarize how factors of the client’s culture may be impacting the response of the client.
IX.
Describe the personality patterns of the client. [COU-680-02]
A. Summarize the general personality characteristics of the client.
X.
Determine the diagnosis justification. [COU-680-04]
A. Use the DSM-5 to justify your diagnosis.
XI.
Describe the treatment targets based on current literature. [COU-680-04]
A. Describe the suggested counseling intervention based on the literature in your trauma toolbox and any additional outside research.
B. Describe the rationale for the intervention based on the literature in your trauma toolbox and any additional outside research.
XII.
Summarize how your trauma toolbox supported the client with your choice of intervention(s). How do you expect you will use it in future work with
clients? [COU-680-04]
2
Weekly Activities
Weekly Activities
Throughout the course, you will participate in weekly activities that will directly support your final project. In these weekly activities, you will be asked to find a
resource or intervention to support a client in a case study. The resource or intervention will then be added to your trauma toolbox within the ePortfolio. At the
end of the course, you will be presented with a more complex case study and will be asked to use your toolbox to support the development of a case
conceptualization and initial intervention proposal.
Final Submission
In Week Nine, you will submit your case conceptualization. This submission will be graded with the Final Project Two Rubric.
Final Project Two Rubric
Guidelines for Submission: The case conceptualization should be 4 to 7 pages in length, formatted as a clinical document, and should use the headings and
outline from the Prompt section above.
Critical Elements
Case
Conceptualization:
Presenting
Concerns
[COU-680-01]
Case
Conceptualization:
Triggers
[COU-680-01]
Case
Conceptualization:
Maladaptive
Patterns
[COU-680-01]
Case
Conceptualization:
Influences
[COU-680-02]
Exemplary (100%)
Meets “Proficient” criteria and
demonstrates a sophisticated
awareness of how the presenting
concerns are affecting the client
Proficient (90%)
Describes the presenting concerns
the client is experiencing
Needs Improvement (70%)
Describes the presenting concerns
the client is experiencing but
contains gaps or inaccuracies
Not Evident (0%)
Does not describe the presenting
concerns the client is experiencing
Value
10.05
Meets “Proficient” criteria and
description is exceptionally clear
and contextualized
Describes the current triggers that
activate the client’s presenting
problem
Does not describe the current
triggers that activate the client’s
presenting problem
10.05
Meets “Proficient” criteria and
demonstrates a sophisticated
awareness of the behavior
Identifies any maladaptive
patterns the client is experiencing
Describes the current triggers that
activate the client’s presenting
problems but contains gaps or
inaccuracies
Identifies any maladaptive
patterns the client is experiencing
but contains gaps or inaccuracies
Does not identify any maladaptive
patterns the client is experiencing
10.05
Meets “Proficient” criteria and
demonstrates a sophisticated
awareness of how the influences
affect the client
Identifies any developmental
influences the client is
experiencing
Identifies any developmental
influences the client is
experiencing but contains gaps or
inaccuracies
Does not identify any
developmental influences the
client is experiencing
6.03
3
Critical Elements
Case
Conceptualization:
Biological
Concerns
[COU-680-02]
Case
Conceptualization:
Prompters
[COU-680-02]
Case
Conceptualization:
Cultural Identity
[COU-680-02]
Case
Conceptualization:
Cultural Stressors
[COU-680-02]
Case
Conceptualization:
Personality
Patterns
[COU-680-02]
Case
Conceptualization:
Diagnosis
Justification
[COU-680-04]
Case
Conceptualization:
Treatment Targets
[COU-680-04]
Case
Conceptualization:
Tool Box:
Intervention
[COU-680-04]
Exemplary (100%)
Meets “Proficient” criteria and
provides exceptional insight to
how the biological concerns are
affecting the client
Proficient (90%)
Describes biological concerns the
client is experiencing
Needs Improvement (70%)
Describes biological concerns the
client is experiencing but contains
gaps or inaccuracies
Not Evident (0%)
Does not describe biological
concerns the client is experiencing
Value
6.03
Meets “Proficient” criteria and
provides exceptional insight to
how the prompters are affecting
the client
Meets “Proficient” criteria and
provides keen insight into how
cultural identity influences the
client
Meets “Proficient” criteria and
provides exceptional insight to
how the cultural stressors are
affecting the client
Meets “Proficient” criteria and
provides exceptional insight to
how the personality patterns are
affecting the client
Describes the prompters the
client is experiencing
Describes the prompters the
client is experiencing but contains
gaps or inaccuracies
Does not describe the prompters
the client is experiencing
6.03
Describes the client’s cultural
identity
Describes the client’s cultural
identity but lacks detail or
contains gaps or inaccuracies
Does not describe the client’s
cultural identity
6.03
Identifies any cultural stressors
that may be influencing the client
Identifies any cultural stressors
that may be influencing the client
but contains gaps or inaccuracies
Does not identify any cultural
stressors that may be influencing
the client
6.03
Describes the personality patterns
of the client
Describes the personality patterns
of the client but contains gaps or
inaccuracies
Does not describe the personality
patterns of the client
6.03
Meets “Proficient” criteria and
provides keen insight as to why
the diagnosis and justification are
accurate
Determines the diagnosis
justification
Determines the diagnosis
justification, but justification is
inaccurate
Does not determine the diagnosis
justification
10.05
Meets “Proficient” criteria and
illustrates a sophisticated
approach to treatment supported
by literature and a strong
rationale
Meets “Proficient” criteria and
provides exceptional insight into
how the trauma toolbox can be
used in clinical practice
Describes the treatment targets
based on current literature and is
appropriate to client treatment
Describes the treatment targets
based on current literature but
contains gaps or inaccuracies
Does not describe the treatment
targets based on current
literature
10.05
Summarizes how the trauma
toolbox supported the client in
the case study and how the
toolbox will be used in future
practice
Summarizes how the trauma
toolbox supported the client in
the case study and how the
toolbox will be used in future
practice but lacks details or
contains inaccuracies
Does not summarize how the
toolbox supported the client in
the case study and how the
toolbox will be used in future
practice
10.05
4
Critical Elements
Articulation of
Response
Exemplary (100%)
Submission is free of errors
related to citations, grammar,
spelling, syntax, and organization
and is presented in a professional
and easy-to-read format
Proficient (90%)
Submission has no major errors
related to citations, grammar,
spelling, syntax, or organization
5
Needs Improvement (70%)
Submission has major errors
related to citations, grammar,
spelling, syntax, or organization
that negatively impact readability
and articulation of main ideas
Not Evident (0%)
Submission has critical errors
related to citations, grammar,
spelling, syntax, or organization
that prevent understanding of
ideas
Total
Value
3.52
100%

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