Athlete Mental Health Screening Note (SMHAT-1 or Other Instruments)

Date/Time of Screening: [Date and time of screening completion]

Date/Time of Clinician Review: [Date and time of clinician review] (Include only if different from screening completion time)

Location/Modality: [in-person / telehealth / team screening event / pre-participation exam]

Sport/Level: [Sport] — [collegiate / elite / professional / youth]

Season Phase: [pre-season / mid-season / end-season / off-season]

Screening Trigger: [routine annual / preseason baseline / mid-season check / post-injury / performance concern / athlete request / clinician concern]

Screening Context

[Reason for screening and any athlete-reported current stressors] (1–3 sentences. Document only athlete-reported factors such as injury status, academic stress, playing time changes, team conflict, or transition concerns. Do not infer stressors from sport context. For routine negative screens with no concerns, a single sentence such as "Routine annual screen; no acute concerns reported" is sufficient.)

Consent and Confidentiality

[Consent documentation and limits of confidentiality reviewed] (Document that athlete consented to screening and that limits of confidentiality were explained, including risk of self-harm, harm to others, abuse reporting, and medical emergencies.)

[Authorized disclosures and boundaries] (Note who has access to results and whether athlete authorized release to athletics staff, coaches, family, or others. Document any declined disclosures and applicable safety exceptions.)

(For electronic/asynchronous screening, note that consent was embedded in platform and whether follow-up discussion occurred.)

Instruments and Results

(Repeat for each instrument administered. Do not calculate scores for incomplete instruments; document "score not calculable" and note clinical follow-up based on available data.)

[Instrument name and version]

• Domain assessed: [distress / depression / anxiety / sleep / alcohol use / substance use / eating disorder risk]
• Timeframe referenced: [Instrument-specific timeframe]
• Administration mode: [self-administered / staff-assisted / interview]
• Completion status: [complete / incomplete]
• Total score: [Numeric total / score not calculable]
• Threshold/cutoff used: [Value and criterion]
• Threshold met: [yes / no]
• Severity category: [none / mild / moderate / moderately severe / severe / not applicable]
• Subscale scores: [Subscales and scores] (Include only when clinically relevant)
• Safety-sensitive item(s): [If suicidality or self-harm item endorsed: exact response, timestamp when available to clinician, and immediate actions taken / no safety-sensitive items endorsed]

Interpretation

[Overall screening impression] (State whether overall screen is negative or positive. Identify domains triggering positive results. Note patterns across instruments and important limitations including self-report nature, situational pressures, disclosure concerns, and cultural considerations. Explicitly state that screening results are not diagnostic and indicate need for further evaluation when positive.)

Triage and Risk Level

• Risk/urgency category: [No acute risk — routine follow-up / Non-urgent positive screen — follow-up within days / Urgent mental health follow-up — same day or within 24 hours / Emergent safety concern — immediate crisis protocol]
• Rationale: [Thresholds met, red flags, or safety item endorsements justifying category]
• Athlete notification: [contacted / left message / not yet reached] — [Date/time] — [phone / secure message / in person]

Safety actions: (Include only if any suggestion of self-harm or harm to others)

• Same-day safety evaluation: [completed / not completed — reason and escalation pathway]
• Emergency services: [activated / not activated / not indicated]
• Safety plan: [established — key components / not established / not indicated] — [Crisis resources provided]

Clinical Follow-up Assessment

(Include this section only when a positive screen triggers same-day clinical evaluation. Omit entirely for routine negative screens.)

Presenting Concerns and Symptom Characterization

• [Onset and duration of symptoms]
• [Functional impairment and impact on training, competition, and academics]
• [Context and modifiers: alleviating/exacerbating factors, relation to training load or competition]

Risk Assessment

• Suicidal ideation: [present — frequency/intensity / absent]
• Plan: [present — specificity / absent]
• Intent: [present / absent]
• Means access: [Lethality considerations]
• Prior attempts or self-injury: [History if any]
• Protective factors: [Supports and reasons for living]
• Risk of harm to others: [present — details / absent]

Mental Status Exam

• Appearance/behavior: [Findings]
• Speech: [Findings]
• Mood/affect: [Findings]
• Thought process/content: [Findings]
• Cognition: [Orientation, attention, memory]
• Insight/judgment: [Findings]

Athlete-Specific Factors

• [Injury status and recovery phase]
• [Concussion history or recent head injury]
• [Overtraining or relative energy deficiency signals]
• [Other relevant sport-related factors]

Assessment

(Include for any positive screen or when follow-up actions are taken. Use problem-oriented framing. Do not assign formal DSM diagnoses unless diagnostic evaluation was performed during this encounter.)

[Problem 1]

[Supporting evidence: instrument, score, threshold met, brief clinical correlation]

[Problem 2]

[Supporting evidence and brief clinical correlation] (Add additional problems as needed)

Plan

• Immediate interventions: [Brief counseling, psychoeducation, or coping strategies provided] (If applicable)
• Referrals: [Licensed mental health professional / psychiatry / sport psychologist / eating disorder specialist / sleep medicine] — [routine / within days / same day] — [Appointment status if known]
• Monitoring and re-screening: [Instruments to repeat, timeframe, and escalation triggers]
• Crisis resources/safety plan: [Resources provided and safety plan elements] (Include for any identified risk)
• Care preferences and barriers: [Athlete preferences, access considerations, cultural or language needs]
• Declined recommendations: [Document refusal, risks discussed, and contingency plan] (If applicable)

(For routine negative screens, minimal plan such as "Routine re-screen at [timeframe]" is sufficient.)

Care Coordination

(Include only if coordination occurred or follow-up is needed. Omit for routine negative screens with no follow-up.)

• Notifications made: [Team physician / athletic trainer / mental health provider] — [Date/time]
• Information shared: [Summary of what was communicated, using minimum necessary principle]
• Consent status: [authorized / declined / safety exception applied]
• Urgent handoff: [Receiving party, time of handoff, confirmation of receipt] (If applicable)