Appendix 1

Worksheets and Checklists

Contents
Cognitive-Behavior Therapy Case Formulation Worksheet
Automatic Thoughts Checklist
Thought Change Record
Examining the Evidence for Automatic Thoughts Worksheet
Weekly Activity Schedule
Schema Inventory
Examining the Evidence for Schemas Worksheet
Cognitive-Behavior Therapy Supervision Checklist

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Cognitive-Behavior Therapy Case Formulation Worksheet

Patient Name:

Date:

Diagnoses/Symptoms:
Formative Influences:
Situational Issues:
Biological, Genetic, and Medical Factors:

Strengths/Assets:

Treatment Goals:

Event 1

Event 2

Event 3

Automatic Thoughts

Automatic Thoughts

Automatic Thoughts

Emotions

Emotions

Emotions

Behaviors

Behaviors

Behaviors

Schemas:

Working Hypothesis:

Treatment Plan:

Automatic Thoughts Checklist

Instructions:

Place a check mark beside each negative automatic thought that you have had in the past 2 weeks.

_____ I should be doing better in life.

_____ He/she doesnt understand me.
_____ Ive let him/her down.
_____ I just cant enjoy things anymore.
_____ Why am I so weak?
_____ I always keep messing things up.
_____ My lifes going nowhere.
_____ I cant handle it.
_____ Im failing.
_____ Its too much for me.
_____ I dont have much of a future.
_____ Things are out of control.
_____ I feel like giving up.
_____ Something bad is sure to happen.
_____ There must be something wrong with me.

Adapted with permission from Wright JH, Wright AS, Beck AT: Good Days Ahead: The Multimedia Program for Cognitive Therapy.
Louisville, KY, Mindstreet, 2004. Permission is granted for readers to use this item in clinical practice.

Source.

a. Write automatic
thought(s) that preceded
emotion(s).
b. Rate belief in automatic
thought(s), 0%100%.

Automatic thought(s)
a. Specify sad, anxious, angry,
etc.
b. Rate degree of emotion,
1%100%.

Emotion(s)
a. Identify cognitive errors.
b. Write rational response to
automatic thought(s).
c. Rate belief in rational
response, 0%100%.

Rational response
a. Specify and rate
subsequent emotion(s),
0%100%.
b. Describe changes in
behavior.

Outcome

Adapted from Beck AT, Rush AJ, Shaw BF, et al: Cognitive Therapy of Depression. New York, Guilford, 1979, pp. 164165. Used with permission.

Describe
a. Actual event leading to
unpleasant emotion or
b. Stream of thoughts
leading to unpleasant
emotion or
c. Unpleasant physiological
sensations.

Situation

Thought Change Record

Examining the Evidence for Automatic Thoughts Worksheet

Instructions:
1. Identify a negative or troubling automatic thought.
2. Then list all the evidence that you can find that either supports (evidence for) or disproves (evidence against) the
automatic thought.
3. After trying to find cognitive errors in the evidence for column, you can write revised or alternative thoughts at the
bottom of the page.
Automatic thought:

Evidence for automatic thought:

Evidence against automatic thought:

1.

1.

2.

2.

3.

3.

4.

4.

5.

5.

Cognitive errors:

Alternative thoughts:

Adapted with permission from Wright JH, Wright AS, Beck AT: Good Days Ahead: The Multimedia Program for Cognitive Therapy.
Louisville, KY, Mindstreet, 2004. Permission is granted for readers to use this item in clinical practice.

9:00 P.M.

8:00 P.M.

7:00 P.M.

6:00 P.M.

5:00 P.M.

4:00 P.M.

3:00 P.M.

2:00 P.M.

1:00 P.M.

12:00 P.M.

11:00 A.M.

10:00 A.M.

9:00 A.M.

8:00 A.M.

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Instructions: Write down your activities for each hour and then rate them on a scale of 010 for mastery (m) or degree of accomplishment and for pleasure
(p) or amount of enjoyment you experienced. A rating of 0 would mean that you had no sense of mastery or pleasure. A rating of 10 would mean that
you experienced maximum mastery or pleasure.

Weekly Activity Schedule

Schema Inventory
Instructions: Use this checklist to search for possible underlying rules of thinking. Place a check mark beside each schema
that you think you may have.
Healthy Schemas

Dysfunctional Schemas

___ No matter what happens, I can manage somehow.

___ I must be perfect to be accepted.

___ If I work hard at something, I can master it.

___ If I choose to do something, I must succeed.

___ Im a survivor.

___ Im stupid.

___ Others trust me.

___ Without a woman (man), Im nothing.

___ Im a solid person.

___ Im a fake.

___ People respect me.

___ Never show weakness.

___ They can knock me down, but they cant knock me out.

___ Im unlovable.

___ I care about other people.

___ If I make one mistake, Ill lose everything.

___ If I prepare in advance, I usually do better.

___ Ill never be comfortable around others.

___ I deserve to be respected.

___ I can never finish anything.

___ I like to be challenged.

___ No matter what I do, I wont succeed.

___ Theres not much that can scare me.

___ The world is too frightening for me.

___ Im intelligent.

___ Others cant be trusted.

___ I can figure things out.

___ I must always be in control.

___ Im friendly.

___ Im unattractive.

___ I can handle stress.

___ Never show your emotions.

___ The tougher the problem, the tougher I become.

___ Other people will take advantage of me.

___ I can learn from my mistakes and be a better person.

___ Im lazy.

___ Im a good spouse (and/or parent, child, friend, lover).

___ If people really knew me, they wouldnt like me.

___ Everything will work out all right.

___ To be accepted, I must always please others.

Adapted with permission from Wright JH, Wright AS, Beck AT: Good Days Ahead: The Multimedia Program for Cognitive Therapy.
Louisville, KY, Mindstreet, 2004. Permission is granted for readers to use this item in clinical practice.

Examining the Evidence for Schemas Worksheet

Instructions:
1. Identify a negative or maladaptive schema that you would like to change, and write it down on this form.
2. Write down any evidence that either supports or disproves this schema.
3. Look for cognitive errors in the evidence for the maladaptive schema.
4. Finally, note your ideas for changing the schema and your plans for putting these ideas into action.
Schema I want to change:

Evidence for this schema:

Evidence against this schema:

1.

1.

2.

2.

3.

3.

4.

4.

5.

5.

Cognitive errors:

Now that Ive examined the evidence, my degree of belief in the schema is:
Ideas I have for modifications to this schema:

Actions I will take now to change my schema and act in a healthier way:

Adapted with permission from Wright JH, Wright AS, Beck AT: Good Days Ahead: The Multimedia Program for Cognitive Therapy.
Louisville, KY, Mindstreet, 2004. Permission is granted for readers to use this item in clinical practice.

Cognitive-Behavior Therapy Supervision Checklista

Therapist _______________________________________________
Supervisor______________________________________________

Date _________________________________

Instructions: Use this checklist to monitor and evaluate competencies in CBT. Listed in Part A are competencies that should
typically be demonstrated in each session. Part B (next page) contains competencies that may be demonstrated over a course
of therapy or therapies. The checklist is not intended for evaluation of performance in first or last sessions.

Part A: Competencies that should typically be demonstrated in each session.

Competency
1. Maintains collaborative empirical alliance

2. Expresses appropriate empathy, genuineness

3. Demonstrates accurate understanding

4. Maintains appropriate professionalism and

boundaries

5. Elicits and gives appropriate feedback

6. Demonstrates knowledge of CBT model

7. Demonstrates ability to use guided discovery

8. Effectively sets agenda and structures session

9. Reviews and assigns useful homework

10. Identifies automatic thoughts and/or beliefs

(schemas)

11. Modifies automatic thoughts and/or beliefs

(schemas)

12. Utilizes behavioral intervention or assists patient

with problem solving

13. Applies CBT methods in flexible manner that meets

needs of patient

Superior

Satisfactory

Needs
improvement

Did not
attempt or N/A

Part B: Competencies that may be demonstrated over a course of therapy or therapies

Competency

Superior

Satisfactory

Needs
improvement

Did not
attempt or N/A

1. Sets goals and plans treatment based on CBT

formulation

2. Educates patient about CBT model and/or therapy

interventions

3. Demonstrates ability to use thought record or other

structured method of responding to dysfunctional
cognitions

4. Can utilize activity or pleasant events scheduling

5. Can utilize exposure and response prevention or

graded task assignment

6. Can utilize relaxation and/or stress management

techniques

7. Can utilize CBT relapse prevention methods

Comments:

Checklist developed by Donna Sudak, M.D., Jesse H. Wright, M.D., Ph.D., David Bienenfeld, M.D., and Judith Beck, Ph.D., 2001.