Diagnostic Intake Evaluation (Pediatric Psychology)

Visit Header

Date of Service: [Date]
Visit Type: [in-person / telehealth]
Location: [Clinic/site and department]
Provider: [Name, credentials]
Participants: [Patient (age); caregivers with relationship; interpreter if used] (Specify which portions each attended: intake history, child interview, measures, feedback.)
Total Time: [Total minutes] (Breakdown: [Face-to-face minutes]; [Records review/collateral minutes] as applicable.)

Referral and Presenting Concern

[Referral source and stated reason] [Chief concern in patient/caregiver words] [Clinical questions to be addressed: diagnosis, functional impact, treatment fit, risk, accommodations] [Relevant specialty context if referred from medical subspecialty]. (Use brief paragraph format; attribute sources throughout, e.g., "Parent reports…," "Patient states…")

Consent and Confidentiality

[Consent/assent obtained from: caregiver(s) and/or patient] [Limits of confidentiality reviewed] [Release(s) of information on file for: school / PCP / specialists / other] [For adolescents: confidential interview was offered / conducted / deferred; documentation of how confidential content is handled per clinic policy].

Sources of Information

• [Informants and relationships]
• [Records reviewed] (e.g., prior evaluations, IEP/504 plans, medical notes)
• [Measures completed] (Names only; details in Screening Measures section)
• [Reliability/limitations of history] (Include only if materially limited.)

History of Present Illness

[Chronological narrative of symptom onset and course] [Current symptom profile from child perspective] [Current symptom profile from caregiver perspective] [Triggers and maintaining factors (medical events, transitions, sleep, pain, adherence conflicts)] [Functional impact across settings: home routines, school attendance/performance, peer relationships, family conflict, health behaviors] [Prior strategies or treatments tried and outcomes] [Patient and caregiver goals for care]. (Attribute information to sources; neutrally document discrepancies between informants.)

Medical and Health History

• [Key medical diagnoses and relevance to functioning]
• [Current medications (psychotropic and medical) with doses; adherence issues; behavioral side effects]
• [Relevant hospitalizations, procedures, or ED visits]
• [Sleep, pain, appetite, toileting status] (Include only if clinically relevant.)

[Brief synthesis linking medical context to presenting concerns and implications for formulation/intervention.]

Psychiatric and Behavioral Health History

• [Prior mental/behavioral health diagnoses and source]
• [Previous therapy: type, duration, response, reason for ending]
• [Prior psychiatric care: outpatient, inpatient, partial, ED visits]
• [Psychotropic medication trials: agents, response, side effects]
• [Self-harm or suicidal ideation/behavior history]
• [Trauma/adversity exposure if relevant: minimal necessary detail; current safety; any mandatory reporting actions] (Document only if explicitly reported or recorded.)

Developmental History

• [Prenatal/perinatal history: complications, exposures, delivery, neonatal course]
• [Early temperament and regulation: sleep/soothing, activity level]
• [Motor milestones: gross/fine motor; age attained]
• [Language milestones: receptive/expressive; age attained]
• [Toileting: onset, regression, enuresis/encopresis if present]
• [Sensory or feeding concerns]
• [Social communication and play development]
• [Behavioral concerns by developmental stage]
• [Early intervention or therapies received: type, duration, response]

(If time-limited, document core elements obtained and note plan to complete at follow-up.)

Family and Social History

• [Household composition and caregiving roles; custody/visitation as known]
• [Family psychiatric history, emphasizing first-degree relatives]
• [Relevant family medical history]
• [Parenting approaches and caregiver capacity]
• [Family stressors and supports]
• [Housing stability and social determinants of health]
• [Peer relationships, activities, screen/media context]
• [Cultural and linguistic factors affecting engagement]
• [Home/community safety concerns]
• [For adolescents: confidential domains assessed per protocol] (Note categories only to preserve confidentiality.)

School and Academic Functioning

• [Grade and school type; for preschoolers: daycare/preschool context]
• [Attendance patterns: tardiness, absences, avoidance]
• [Academic strengths and areas of concern]
• [Behavior supports or disciplinary history]
• [IEP/504 status: eligibility, accommodations, services]
• [Social functioning at school: peers, bullying]
• [School-based mental health supports]

Strengths and Protective Factors

• [Child strengths: interests, talents, positive relationships, coping skills]
• [Family strengths: engagement, support, resources, routines]
• [Other protective factors relevant to risk and recovery]

Behavioral Observations and Mental Status Examination

(Use descriptive, developmentally informed language. Place only observed behaviors here; reserve interpretation for Diagnostic Formulation.)

• Appearance/Behavior: [Grooming, motor activity, separation behavior, transitions, cooperation, play themes; caregiver-child interaction quality]
• Speech/Language: [Rate, volume, articulation; language complexity for age]
• Mood and Affect: [Patient's words for mood if possible; range, reactivity, congruence]
• Thought Process/Content: [Organization, associations; preoccupations, themes]
• Perception: [Hallucinations or perceptual disturbances as assessable]
• Attention/Cognition: [Clinical impression of attention, orientation, memory appropriate to developmental level]
• Insight/Judgment: [Developmentally appropriate appraisal]
• Impulse Control: [Observed self-regulation during session]
• [Domains not assessable] (State explicitly if any domain could not be evaluated due to age or context.)

Screening Measures and Rating Scales

(Include this section only if measures were administered or are pending.)

• [Measure name] — [Informant] — [Date] — [Score(s) with interpretive range] — [Brief clinical interpretation; note validity concerns]
• [Additional measures as applicable]
• [Measures pending with plan to review]

Risk Assessment and Safety Planning

(Required section. Assess and document explicitly. If youth was not present, state limitations and mitigation steps.)

• Suicide risk: [Ideation frequency/intensity/duration; presence/absence of plan, intent, means; history of attempts/NSSI; triggers; protective factors]
• Homicide/violence risk: [Threats, intent, access to weapons, contextual triggers]
• Abuse/neglect/exploitation concerns: [Current concerns; mandatory reporting actions if indicated]
• Access to lethal means: [Firearms, medications, sharps; counseling provided]
• Medical risk behaviors: [Nonadherence, dangerous compensatory behaviors, substance use] (Include only if relevant.)

Risk Level: [low / moderate / high] — [Brief justification]
Actions Taken Today: [Safety plan details; crisis resources provided; means restriction steps; referrals; reports filed]
Follow-Up Interval Based on Risk: [Timeframe and rationale]

(If essential safety information is missing, note why and document plan to obtain.)

Diagnostic Formulation

[Integrative case conceptualization synthesizing multi-informant history and observations. Include predisposing factors (developmental, temperament, family history), precipitating factors (medical events, transitions, trauma), perpetuating factors (avoidance, accommodation, sleep disruption, reinforcement patterns), and protective factors. Explain how medical, developmental, family, and school factors interact to produce the current presentation.] (Provide integration, not repetition of raw data. Do not infer unreported trauma or diagnoses.)

Diagnoses

• [Primary diagnosis most responsible for impairment] — [meets criteria / provisional / subthreshold] — [Brief rationale]
• [Secondary diagnoses, if any] — [meets criteria / provisional / subthreshold] — [Brief rationale]
• [Relevant medical diagnoses impacting treatment]
• [Psychosocial/contextual factors (Z codes)]

(Base diagnoses only on explicitly documented criteria. If uncertainty remains, specify rule-outs and plan to clarify.)

Medical Necessity Statement

[Current symptoms and duration] [Functional impairments across settings] [Why services are needed now: risk level, severity, interference with medical care or development] [Why pediatric psychology is appropriate: developmental expertise, family-based intervention, integrated care] [Expected benefits and measurable targets] [Patient/family engagement capacity].

Treatment Plan

(Prioritize safety and highest impairment. If elements depend on pending data, document interim plan and triggers for update.)

Target 1: [Problem/behavioral target]

• Target behavior(s): [Operationalized definition; baseline if known]
• Goal and timeframe: [Measurable goal with expected timeframe]
• Intervention approach: [Evidence-based modality and components]
• Caregiver/family component: [Parent training, coaching, family sessions]
• Coordination: [School team, PCP, specialists]
• Measurement plan: [Rating scales, session metrics, school data]
• Frequency and modality: [Session frequency; in-person / telehealth / hybrid]

Target 2: [Problem/behavioral target]

• [Plan elements as above]

[Safety plan and crisis protocol if indicated] [Psychoeducation topics covered today] [Homework/practice assignments]

Care Coordination and Follow-up

• [Referrals placed today]
• [Collateral contacts planned: school, PCP, specialists]
• [Resources provided]
• [Follow-up interval and focus]
• [School recommendations: accommodations, attendance plan, communication strategy]

Signature

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

Documentation guidance: Attribute information to sources throughout. Document informant discrepancies neutrally. Place observations in Behavioral Observations/MSE; interpretation in Diagnostic Formulation. For missing essential safety information, include placeholder with plan to obtain. Omit nonessential missing information rather than inserting N/A. Do not infer diagnoses, trauma, abuse, or adherence without explicit documentation.