Psychotherapy Assessment Checklist (PAC)

PAC forms allow therapists to gather a great deal of information and screen it rapidly. Patients fill out information about presenting problems, life history overview, and DSM-IV diagnoses on all five axes. The one-page PAC Summary Form allows the therapist to summarize the patient’s information from the PAC Forms. The PAC Follow-Up forms can be used to assess therapeutic change after termination.

The PAC Forms themselves (7 pages) are available in English, Norwegian (translated by Elisabeth Schanche), Dutch (translated by Cindy Wiebrands), and Spanish (translated by Enrique de-Urquiza). The Follow-Up forms are available in English and Norwegian. DSM-5 PAC and SummaryForm (created by Laurene Wilson) is available only in English.

The forms are free to download and use with your patients and are available in both PDF (requires Adobe Acrobat Reader) and RTF (downloads to a Word document) format.

PAC downloads

PAC forms:

English PDF | RTF

Norwegian PDF | RTF

Dutch PDF

Spanish PDF | RTF

Follow-up forms:

English PDF | RTF

Norwegian PDF | RTF

Summary form for therapist PDF | RTF

DSM 5-PAC Forms


DSM 5-PAC Summary Form PDF

Further reading about PAC

Instruction Manual: a supplementary article to Treating Affect Phobia.

Instruction Manual


Ten-session summary form

The Ten-Session Summary Form is used to summarize and rate therapy sessions. Once a form is completed, a new one can be started for the same patient.

For each session, the form records the date, a brief summary of the main themes of the session, the core affective conflict focused on in the session, and a 1-10 rating of the intensity at which the patient experienced the adaptive affect. In addition to that, there is a separate space to rate a number of items three times at regular intervals over the course of the ten sessions. These items include the five-axis diagnosis, ratings of target problems (1 = no longer a problem, 10 = very severe problem), and ratings of the core conflicts.

The ratings of the target problems and core conflicts can be done by the patient and the therapist together in the last five minutes of a therapy session. This can be helpful to the therapy process.

Ten-session summary form download


The Affect Phobia Test

The Affect Phobia Test was developed by McCullough and co-workers simultaneously in English and Norwegian (McCullough, Berggraf, & Ulvenes, 2010) as a screening instrument to estimate fear of affects and the capacity for adaptive affective functioning. It was translated into Swedish in 2012. The instrument is structured to measure affect phobia in different affective domains. The first evaluation of the psychometric properties of the Affect Phobia Test, using the Swedish version (Frankl, Philips & Wennberg, submitted), show that the empirical cut-off for adaptive affective functioning should be set at >72 points and that the test should be considered as measuring the degree of adaptive affective functioning as a whole.
Chinese translation courtesy of Maple Wong 

Triangle Form

The Patient Forms were developed by Leigh McCullough and her colleagues at SAPU. These forms can be used by the therapist or the patient.

Patient Triangles Form

English PDF | DOC

Swedish PDF

Two Triangle Form

The Two Triangle Form was developed by Kristin Osborn and Jenny Svebeck.

Two Triangle Form

English PDF

Swedish PDF

The Activating Affects Form

The Activating Affects Form was developed by Leigh McCullough.

The Activating Affects Form


Core-Conflict Session Rating

The Core-Conflict Session Rating Form was developed by Leigh McCullough and her colleagues at Modum Bad. It can be used with your patient.

Core-Conflict Session Rating Form


Ronete CohenForms