Chronic Pain Psychology Evaluation Note

Date/Time: [Date and time] Visit Type: [in-person / telehealth] Duration: [Total minutes] Location: [Clinic location or telehealth platform and patient location]

Patient: [Patient name] DOB: [DOB] MRN: [MRN]

Clinician: [Clinician name, credentials] Referral Source: [Referring clinician/service] Referral Question: [Specific referral question or goals]

Chief Concern and Evaluation Objectives

"[Patient's stated reason for the visit in a brief direct quote]"

[Evaluation objectives] (Summarize aims: identify psychosocial pain contributors; assess readiness for self-management treatment; clarify functional goals and barriers; screen for mood, sleep, and substance-related factors as applicable; develop recommendations for the interdisciplinary pain plan.)

Consent and Confidentiality

[Consent and confidentiality statement] (Document that the patient consented to pain psychology evaluation, understood its purpose, and that limits of confidentiality were reviewed including risk of harm, mandated reporting, and care coordination. Note permission obtained for provider coordination if applicable.)

Sources of Information

• [Patient interview]
• [Chart materials reviewed] (Pain clinic notes, imaging summaries, medication list, prior behavioral health records as applicable.)
• [Collateral sources] (Include only if obtained with consent; identify relationship and contact method.)
• [Validated measures administered] (List each instrument with date and mode. If no measures used, briefly note rationale.)

Pain History

[Onset, trigger, and trajectory] (Describe onset timing, precipitating events, and course: [stable / progressive / episodic].)

[Flare pattern and variability] (Frequency, duration, predictability, and variability across days/weeks.)

[Primary location(s), quality, and intensity] (Include typical/worst/best intensity with scale.)

[Aggravating and alleviating factors]

[Associated symptoms] (Include only when relevant to the pain presentation.)

[Patient understanding of cause] (Document beliefs, questions, and any diagnostic uncertainty.)

[Prior and current treatments] (Medications with benefit, side effects, adherence barriers; procedures/surgeries/injections; PT/OT/complementary therapies; prior pain psychology or self-management attempts.)

[Pain-related beliefs and expectations] (Note beliefs influencing behavior, fear, avoidance, or catastrophizing.)

Functional Impact

[Impact on ADLs, mobility, work/school status, accommodations, caregiving, and social/recreational participation]

[Activity pattern] (Characterize as [avoidance / boom-bust cycling / pacing attempts / deconditioning].)

[Valued activities lost and priorities to regain]

[Standardized pain interference measure results] (Include if administered.)

Psychosocial Pain Factors

(Include this section only when psychosocial contributors are present or suspected; otherwise omit entirely.)

[Cognitive-affective pain processes] (Catastrophizing themes, fear of movement/reinjury, safety behaviors, hypervigilance, low pain self-efficacy, perceived injustice.)

[Mood symptoms] (Depression and anxiety features; document trauma-related symptoms only when clinically indicated via targeted inquiry.)

[Current stressors and protective factors] (Financial, housing, legal, relational stressors; supportive relationships and coping strengths.)

[Sleep assessment] (Insomnia pattern: [onset / maintenance / early awakening]; schedule variability; sleep–pain interaction; screening results if used. Note red flags for sleep-disordered breathing requiring medical referral.)

[Synthesis of psychosocial pattern] (Brief integrative summary linking the above findings.)

Substance Use and Medication Safety

(Include this section when opioids or CNS depressants are present or when concern exists; otherwise omit entirely.)

• [Alcohol, cannabis, and other substance use patterns] (Brief, nonjudgmental description.)
• [Medication safety considerations] (Opioids/CNS depressants, concurrent sedatives, respiratory risk factors.)
• Risk flags: [present / not present / not assessed] (If present, specify: history of overdose, SUD treatment, misuse of prescribed medications, concurrent sedatives with risk factors.)
• [Naloxone status] (Include if relevant.)
• [PDMP or toxicology coordination plan] (Specify who will do what; do not imply it already occurred.)

Behavioral Health History

• [Prior psychiatric diagnoses and treatments] (Therapy types, response, medications if known.)
• [Psychiatric hospitalizations]
• [Self-harm or suicide attempts]
• [Relevant family psychiatric history]
• [Previously effective coping strategies and treatments]

Social and Cultural Context

[Living situation and key relationships]

[Employment/disability/compensation claim status] (Document neutrally.)

[Education and literacy considerations]

[Cultural or spiritual factors affecting pain meaning and coping]

[Home safety concerns] (Include only if indicated.)

Mental Status Examination

• Appearance and behavior: [Appearance and behavior]
• Psychomotor activity: [Psychomotor activity]
• Speech: [Speech]
• Mood: [Mood]
• Affect: [Affect] (Range and congruence.)
• Thought process: [Thought process]
• Thought content: [Thought content] (Include salient pain-related beliefs.)
• Perception: [Perception]
• Cognition: [Cognition] (Orientation/attention as needed.)
• Insight and judgment: [Insight and judgment]
• Engagement/reliability: [Engagement and reliability of self-report] (Include only when clearly supported by evidence.)

Risk Assessment and Safety Planning

Suicide/self-harm screening: [Tool or method used]. [Findings: no ideation / passive ideation / active ideation with plan/intent/means]. [Prior attempts]. [Protective factors].

• Risk factors: [Relevant risk factors]
• Protective factors: [Protective factors]
• Clinical judgment: [low / moderate / high] — [Brief rationale]
• Interventions: [Actions taken] (Safety plan, crisis resources provided, coordination with other providers, escalation to higher level of care.)

Other safety concerns: [Homicide/violence risk, withdrawal risk, abuse/neglect reporting] (Address only when clinically indicated; otherwise omit this line.)

(If risk screening not performed, document: "Not assessed — [reason].")

Standardized Measure Results

(Include this section only when measures were administered; otherwise omit entirely.)

• [Instrument name]: [Score] — [Clinical interpretation/severity]. [Validity considerations]. [How results inform formulation and plan].
• [Additional instrument]: [Score] — [Interpretation]. (Repeat as needed.)

Biopsychosocial Formulation

[Integrated conceptualization linking documented findings across domains]

• Predisposing factors: [Documented predisposing factors]
• Precipitating factors: [Injury, surgery, major life events as documented]
• Perpetuating factors: [Fear-avoidance, catastrophizing, insomnia, deconditioning, mood symptoms, medication effects, social reinforcement — include only if documented]
• Protective factors: [Motivation, strengths, supports, prior treatment response]

[Readiness for change and treatment fit]

Primary treatment targets (3–6, prioritized):

• [Treatment target 1] — [Rationale tied to documented facts]
• [Treatment target 2] — [Rationale]
• [Treatment target 3] — [Rationale]
• [Additional targets as indicated]

Diagnoses

• [Mental health diagnosis] [DSM/ICD code]
• [Additional mental health diagnosis] [DSM/ICD code] (Include only if supported.)
• [Diagnosis deferred — reason and plan to clarify] (If applicable.)
• [Relevant medical diagnoses from chart/patient report] (As context; do not diagnose outside scope.)

Plan

Functional Goals

• [Goal 1] (Concrete, patient-centered, measurable.)
• [Goal 2]
• [Goal 3] (Optional.)

Pain Psychology Interventions

• [Target] → [Intervention] → [Homework]
• [Additional target] → [Intervention] → [Homework]

(Select interventions based on formulation: pain neuroscience education; CBT targets such as catastrophizing reappraisal, behavioral activation; ACT targets such as values clarification, acceptance, defusion; graded exposure for fear-avoidance; pacing and activity scheduling; flare planning; relaxation training; mindfulness skills; CBT-I for insomnia; communication skills training.)

Coordination and Referrals

• [Interdisciplinary coordination] (Specify who will do what and timelines.)
• [Referrals placed or recommended]

Monitoring

[Outcomes to track and cadence] (Pain interference, function, sleep, mood; frequency of measurement.)

Follow-up

[Visit frequency] for [expected treatment duration] with reassessment at [timepoint].

[Contingency plans for missed appointments, safety concerns, or symptom escalation]

Signature

Clinician Signature: [Name, credentials, date/time]

Supervision Attestation: [Supervisor name, credentials, attestation statement] (Include if trainee note; otherwise omit.)

Documentation guidance: Attribute sources clearly—"Patient reports..." for patient-reported content, "Clinician observes..." for clinical interpretation. Use direct quotes selectively for key statements. For required domains not assessed, document "Not assessed (reason)" or "Denies/No concerns endorsed." Omit conditional sections entirely when not clinically relevant. Do not infer trauma, substance misuse, or diagnoses without documented evidence; if suspected, document as "concern for..." with objective indicators and plan to assess.