Adaptive Formulation and Outcome Review Sheet

Use the brief worksheet or the fuller records below with the IEMT Treatment Plans workflow and Roy-informed governing principles. It is a proposed planning aid, not a validated assessment scale or diagnostic instrument. It does not establish that IEMT is suitable for a particular person.

Copy the prompts into your practice records or use the printable sheet. Add detail where the work requires it. Keep completed records in your secure practice system; do not enter client information on this public wiki.

Download the one-page printable worksheet (PDF)

Use once at the start, then revise when new information changes the formulation. “Not known”, “not relevant” and the client's disagreement are valid entries. Ask only for information needed for the work. The mode prompts draw on Roy; the record structure and decisions are proposed IEMT applications.

ASSESSMENT AND WORKING FORMULATION
Client reference / practitioner / date:
Communication, access or cultural considerations relevant to this work:
 
Chosen life outcome, in the client's words:
Why it matters / the priority agreed today:
 
Present response: situation, frequency, what happens before and after:
Client's report:
Practitioner's observations:
When it is different / what already helps:
 
Focal stimulus (what is most immediate now):
Contextual factors (what contributes to its effect):
Residual influences (possible factors whose effect is unclear):
Target content: remembered / current / anticipated / other:
Resources, constraints and relevant existing care:
 
Four modes: note a strength, a difficulty and any action wanted now.
Physiological - rest, comfort, activity and relevant health needs:
Self-concept - meanings about self, values and identity:
Role function - responsibilities, expectations and limits:
Interdependence - support, relationships and boundaries:
 
Working explanation and the observations supporting it:
Alternative explanation / what remains unknown:
What the client agrees with, disputes or wants to change:
Needs outside the practitioner's role / action required:

Keep the life outcome separate from any session target. An IEMT target is optional: the agreed plan may prioritise practical support or another service. The planning workflow explains the choices.

ACTION AND OUTCOME AGREEMENT
Client reference / date / agreed priority:
 
Life outcome:
Everyday indicator / baseline / observation period:
Target experience, if relevant / baseline description or rating:
If using a scale: name, version, anchors and reference situation:
What the client would regard as useful progress:
 
Options considered, including deferring or declining IEMT:
Chosen action and why it fits this formulation:
IEMT target and proposed procedure, if appropriate:
Expected benefit, uncertainty and relevant risks discussed:
Consent / agreed way to pause or stop:
 
For each action: what / who / by when / how completion will be checked:
Practical changes or support:
Other assessment, referral or coordination:
Any agreed information sharing and its limits:
What to do if the action or support is unavailable:
 
Review date or event / method / who will arrange it:
Circumstances prompting an earlier review or other help:

Use a new entry for each session or agreed follow-up. Keep earlier entries so that changes in the target, measurement conditions and formulation remain visible. This is a documentation aid, not a requirement to continue sessions until every field shows improvement.

SESSION / FOLLOW-UP REVIEW
Client reference / date / session or follow-up:
Original plan and outcome being reviewed:
Time since intervention / period covered by this review:
 
Changes in priorities, consent, circumstances or other care:
What was actually undertaken today, if anything:
Agreed target / modification / pause or stopping of a procedure:
 
Client's account of change, including what remains difficult:
Practitioner's observations (kept distinct from interpretation):
Target experience: baseline / current / same conditions or different:
Everyday indicator: baseline / current / observation period:
Did a relevant opportunity occur? If not, record this as unknown.
Relevant four-mode changes, strengths retained or new difficulties:
Unwanted effects or deterioration reported / action taken:
Other explanations or concurrent changes:
 
Client's view: was the change useful, and is more work wanted?
Formulation: retain / revise / still uncertain, with reasons:
Decision: continue / revise / conclude / pause / refer:
Reason, remaining needs and limits of the available information:
Next action / responsible person / timing:
Further review or route to appropriate help, if needed:

For interpretation, see the review decision table, Measuring Therapeutic Change and follow-up across time and settings. A missing follow-up is an unknown outcome. Record an agreed contact attempt if one occurs; do not infer why the client did not respond.

• A stimulus category is about its place in the present formulation. A past event is not automatically residual, and an anticipated event can be the immediate focal stimulus. See the planning workflow for definitions and examples.
• The outcome belongs in the person's life. Record a practical indicator alongside any target feeling. Lower distress and improved functioning are related questions, not interchangeable measures.
• Uncertainty and disagreement are useful information. Record “not known” where appropriate. A wish to stop, an imprecise rating or a report of no improvement does not itself establish resistance.

The planning illustrations introduce a possible IEMT target and a situation where practical support takes priority. The separate Worked Examples: Assessment, Planning and Review page completes three fictional records: less distress without participation, practical support taking priority, and missing follow-up. All people, ratings and outcomes in those records are invented teaching material, not treatment evidence.

The categories and mode names come from the Roy Adaptation Association's account of the model. The prompts and their application to IEMT are proposals developed for this wiki, rather than a worksheet authored or validated by Roy.