Initial Evaluation Note (Art Therapy)

Patient Name: [Patient full name]   DOB: [Date of birth]   MRN: [Medical record number]
Date of Service: [Date]   Session Duration: [Total minutes]   Setting: [in-person / telehealth] (If telehealth, include patient and provider locations; if in-person, include clinic/site.)
Service Type: Initial Evaluation (Art Therapy)   Participants Present: [Participant names and roles]   Provider: [Provider name, credentials]

(If any required header field is unknown at documentation time, enter "Unknown" or "Not documented" with a brief explanation rather than leaving blank.)

Reason for Referral

[Referral source, referral question in referrer's terms, precipitating context, and chief concern in patient's or caregiver's own words if available] (Format as 1–3 sentences of narrative; include additional supporting details only if needed for clarity.)

Consent & Art Therapy Permissions

(Include this section only when initiating care; otherwise omit entirely.)

• [Consent/assent obtained from whom, relationship, and date]
• [Limits of confidentiality reviewed]
• [Artwork storage and handling plan at termination]
• [Photography permission: permitted / not permitted / deferred] (If permitted, note where images are stored and any access restrictions.)
• [Restrictions on use of artwork or images beyond treatment]
• [If consent incomplete: what was addressed, what remains, and plan to complete]

Data Sources

(Include only when history is obtained from collateral sources or reliability is limited; otherwise omit.)

• [Informants and relationship to patient]
• [Interpreter used: yes / no] (If yes, note language and modality.)
• [Reliability of information: good / fair / limited] (Brief justification.)

History of Present Problem

[Narrative of current concerns including onset, course, relevant symptoms across emotional/behavioral/cognitive/relational domains, precipitating stressors, what helps and does not help, patient goals and motivation, and functional impact] (If a clinically relevant domain was not assessed, state "Not assessed" with brief reason.)

• [Severity and frequency anchors]
• [Triggers and contextual patterns]
• [Aggravating and relieving factors]
• [Safety-related behaviors or signals] (Include only if applicable.)

Relevant History

(Include only elements pertinent to the formulation and referral question.)

• [Developmental history highlights] (Include only if clinically relevant.)
• [Family and relationship context]
• [Education or work functioning]
• [Medical history and current medications]
• [Psychiatric history: prior diagnoses, hospitalizations, past treatments and response]
• [Substance use] (Include only if applicable.)
• [Current services and care team]
• [Trauma exposure: categories and timeframe / Patient declined to discuss / Not assessed] (Use minimum necessary detail; note any mandatory reporting actions taken.)

Strengths, Interests & Protective Factors

• [Individual strengths, including at least one patient-identified strength when available]
• [Creative interests and preferred art materials or processes]
• [Social supports and caregiving resources]
• [Cultural and community resources relevant to care]
• [Prior successful coping strategies]

Mental Status Examination

(Use brief, objective descriptors; avoid conclusions without supporting observations.)

• [Appearance and grooming]
• [Behavior and psychomotor activity]
• [Speech: rate, volume, articulation]
• [Mood (subjective) and Affect (observed): range, congruence, reactivity]
• [Thought process and content]
• [Perception] (Include only if assessed.)
• [Cognition: orientation, attention, memory] (As appropriate to presentation.)
• [Insight and judgment]
• [Tolerance for novelty and uncertainty; sensory regulation]
• [Communication style: verbal / nonverbal preference]
• [Capacity for symbolic expression and reflection]
• [For children: play engagement, separation behavior, caregiver interaction] (Include only if applicable.)

Art Therapy Assessment Observations

(Include this section only when art-making occurred during the evaluation; otherwise omit entirely.)

• Directive/Task: [Prompt, materials offered, level of structure, time allotted]
• Process Observations: [Material selection, sequencing, persistence, problem-solving, pacing, tolerance of mistakes, help-seeking, interpersonal dynamics during art-making] (Objective description only.)
• Client's Narrative: [Client's description, title, story, emotions, and associations in their own words]
• Product Description: [Size, use of space, color, line, form, organization, notable repetitions or omissions] (Objective formal elements; avoid aesthetic judgment.)
• Therapist Interpretation: [Clinical hypothesis linking observations to presenting concerns and function] (Clearly label as hypothesis; distinguish inference from observed fact.)
• Artwork Disposition: [Storage location; patient retained: yes / no; photographed: yes / no; photography consent status]

Risk Screening & Safety

(Always include at minimum a screening statement. Never omit risk documentation in an initial evaluation.)

• [Suicidal ideation: present / absent] (If present, document ideation, plan, intent, means access, past attempts, protective factors, impulse control.)
• [Self-harm/NSSI: present / absent] (Detail as above if present.)
• [Homicidal ideation or violence risk: present / absent] (Detail as above if present.)
• [Abuse/neglect concerns: present / absent] (Minimum necessary detail; note mandated reporting actions if applicable.)
• [Overall risk level: low / moderate / high] (Brief justification based on specific findings.)
• [Safety and mitigation plan: safety plan elements, means restriction, crisis resources provided, emergency contacts, follow-up timeline]
• [If risk not assessed: reason and immediate plan to assess]

Functional Baseline

• [School or work functioning: attendance, performance, accommodations]
• [Relationships and social participation]
• [Sleep: duration, quality, disturbances]
• [Appetite and nutrition]
• [ADLs and self-care]
• [Emotional regulation and coping]
• [Participation in meaningful activities and creative engagement]
• [Standardized measures: measure name, score, interpretation, date] (If no measures used, provide narrative anchors for severity and frequency.)

Clinical Formulation

[Integrative summary linking referral question, key history, functional impact, strengths, and risk; predisposing, precipitating, perpetuating, and protective factors; cultural and contextual considerations; diagnostic impression or "Diagnosis deferred" with reason] (Format as 3–5 sentences; clearly distinguish tentative hypotheses from established findings.)

Problem List & Treatment Plan

• [Problem 1]: [Concise problem statement]
  • [Supporting evidence and relevant strengths]
  • Goal: [Measurable target with criterion and timeframe]
  • Interventions: [Art therapy approaches linked to goal]
• [Problem 2]: [Concise problem statement]
  • [Supporting evidence and relevant strengths]
  • Goal: [Measurable target with criterion and timeframe]
  • Interventions: [Art therapy approaches linked to goal]
• (Add additional problems as needed, 3–6 total. If goals cannot be set, document "Goals deferred" with reason and plan to finalize.)

Frequency & Duration: [Recommended session frequency and treatment duration]

Coordination & Referrals: [Care team coordination needs, consults, additional services]

Rationale for Art Therapy

[Mechanism-of-fit statements connecting patient factors to art therapy utility, such as: nonverbal processing needs, sensory-based regulation, affect tolerance via externalization, narrative integration, identity exploration, or engagement when talk therapy alone is insufficient; any contraindications or precautions and planned adaptations]

Disposition & Follow-Up

• [Disposition: continue outpatient art therapy / refer elsewhere / not appropriate at this time] (Include rationale if not continuing.)
• [Next appointment: date or timeframe, modality, any tasks before next visit]
• [Safety follow-up timeline] (Include only if applicable.)
• [Attachments referenced: rating scales, safety plan location, artwork storage details] (Include only if applicable.)

Signature: [Name, credentials, date, time]