Patients name:

Date:

Diagnosis: Axis I

Axis II

Relevant Childhood Data

Which experiences contributed to the development and maintenance of the core belief(s)?

Core Belief(s)
What are the patients most central beliefs about him/herself?

Conditional Assumptions/Beliefs/Rules
Which positive assumption help him/her cope with his/her core belief(s)?
What is the negative counterpart of this assumption?

Compensatory/Coping Strategy(ies)
Which behaviors help him/her cope with the belief(s)?

Situation 1
What was the problematic
situation?

Situation 1

Situation 1

Automatic Thought
What went through his/her mind?

Automatic Thought

Automatic Thought

Meaning of the A.T.

What did the automatic thought
mean to him/her?

Meaning of the A.T.

Meaning of the A.T.

Emotion
What emotion was associated
with the automatic thought?

Emotion

Emotion

Behavior
What did the patient do then?

Behavior

Behavior

FIGURE 13.1. Cognitive Conceptualization Diagram. Adapted from Cognitive behavior

therapy worksheet packet. Copyright 2011 by Judith S. Beck. Bala Cynwyd, PA: Beck Institute for Cognitive Behavior Therapy.
Reprinted by permission in Cognitive Behavior Therapy: Basics and Beyond, Second Edition, by Judith
S. Beck (Guilford Press, 2011). Permission to photocopy this material is granted to purchasers of
this book for personal use only (see copyright page for details).