Initial Evaluation Note (Health Psychology)

Note Type: Initial Evaluation Note - Health Psychology

Date of Service: [Date]

Location/Service: [Clinic/location and service line; modality: in-person / video / phone]

Referring Clinician and Referral Question: [Referring clinician name, role; referral question]

Clinician: [Clinician name, degree(s), license]

Participants: [Patient; collateral present if any; interpreter if used]

Sources of Information: [Patient report / chart review / collateral / questionnaires administered]

(Use patient-centered, non-judgmental language throughout. Attribute discordant information to its source. Omit sections that do not apply; when clinically expected information is missing, document "Not assessed" with reason and plan to obtain.)

Reason for Referral & Presenting Concern

• [Referral question from medical team]
• [Patient's stated goal or chief concern] (Brief direct quote acceptable if it clarifies motivation.)
• [Target medical condition and phase of care: new diagnosis / flare / perioperative / rehabilitation / survivorship / chronic management]
• [Why now: risk, treatment disruption, quality-of-life impact, or barriers affecting care]

(Use 3–6 bullets or convert to a concise paragraph.)

History of Present Illness

[Integrated narrative of biopsychosocial factors affecting the medical condition and its management] (Approx. 6–12 sentences covering: brief medical timeline—onset, course, recent changes; current symptoms and functional impact—sleep, work, activity tolerance, participation in care; health behaviors and self-management—medication adherence, diet, physical activity, sleep schedule, device use, engagement with PT/rehab; cognitive and affective factors—health beliefs, illness perceptions, fear-avoidance, catastrophizing, self-efficacy, readiness; current stressors, coping efforts, supports; prior behavioral/psychological interventions for this condition; patient priorities and goals. Attribute to patient, chart, or collateral when sources conflict.)

• [Key barriers to optimal self-management and care participation]
• [Maintaining factors—behavioral, cognitive, emotional, or contextual]

Relevant Background History

(Include only subsections that are clinically relevant. Use "Unknown" if patient does not know; "Unable to assess" with reason if patient cannot provide.)

• Past Behavioral Health History: [Prior diagnoses; therapy history; psychiatric hospitalizations; relevant medication trials; trauma exposure—document minimally]
• Medical/Surgical History: [Conditions influencing current presentation or treatment feasibility]
• Current Medications: [Psychotropic, pain, sleep, and other meds affecting mood/arousal/appetite; adherence issues and side effects if relevant]
• Family History: [Psychiatric or substance history relevant to risk or formulation]
• Social History: [Living situation; caregiving demands; work/role; transportation/finances; access barriers; cultural factors]
• Substance Use: [Pattern and recent changes; relation to medical condition and treatment adherence]

Behavioral Health Symptom Review

(Include only domains relevant to risk stratification, differential diagnosis, or intervention choice. Omit this section entirely if symptoms are not present or not relevant.)

• Depression/Anhedonia: [Severity, duration, triggers, functional effect]
• Anxiety/Panic: [Severity, duration, triggers, avoidance behaviors, functional effect]
• Trauma Symptoms: [Re-experiencing, hyperarousal, avoidance; relevance to medical care]
• Sleep Disturbance: [Onset/maintenance/early awakening; schedule regularity; impact on fatigue/pain]
• Cognitive Symptoms: [Attention, memory, brain fog; effect on self-management]
• Somatic Symptom Amplification: [Pattern, health care use, reassurance seeking]
• Disordered Eating: [Restrictive/binge/purge behaviors; impact on condition]
• Grief/Adjustment: [Losses, diagnosis adjustment, role changes; intensity and course]

Mental Status Examination & Behavioral Observations

• Appearance & Behavior: [Grooming, attire, posture, eye contact, psychomotor activity, cooperation]
• Speech: [Rate, volume, articulation, fluency]
• Mood & Affect: [Patient-reported mood; observed affect—range, congruence, stability]
• Thought Process & Content: [Coherence, goal-directedness; delusions/obsessions/ruminations present or absent]
• Perception: [Hallucinations or perceptual disturbances present or absent]
• Cognition & Orientation: [Orientation; attention; memory; abstraction] (Note capacity-related observations affecting care participation.)
• Insight & Judgment: [Health insight; decision-making relevant to treatment adherence]
• Engagement & Learning Style: [Motivation/readiness; response to feedback; preferred learning modalities]
• Relevant Medical Data Reviewed: [Data directly supporting formulation—e.g., A1c trend, CPAP adherence, pain scores] (Include only if it informs assessment.)

Risk & Safety Assessment

(This section must be explicitly addressed in every initial evaluation, even if negative.)

• Suicide/Self-Harm: [Current ideation: none / passive / active; plan: yes / no; intent: yes / no; preparatory behaviors: yes / no; past attempts or self-injury: type, recency, lethality]
• Violence Risk: [Ideation: yes / no; intent: yes / no; recent aggressive behavior: yes / no; specific targets or access to means]
• Protective Factors: [Reasons for living; social supports; treatment engagement; spiritual/cultural factors; responsibilities]
• Overall Risk Formulation: [Acute risk: low / moderate / high; Chronic risk: low / moderate / high; key drivers and mitigators]
• Risk Mitigation Plan: [Safety plan steps; crisis resources provided; means restriction; follow-up interval; escalation criteria] (If risk not assessed, document why and plan to assess.)

Assessment & Case Formulation

[Concise clinical summary linking presenting concerns to functional impairment and medical outcomes] (3–6 sentences. Be explicit about what is inferred vs reported/observed.)

• Biological Factors: [Illness course; pain physiology; sleep disruption; medication effects]
• Psychological Factors: [Anxiety/depression; avoidance; catastrophizing; trauma triggers; health beliefs]
• Social/Contextual Factors: [Caregiving burden; work demands; financial strain; access barriers; cultural considerations]
• Maintaining Factors: [Behaviors, cognitions, emotions, or environmental contingencies sustaining the problem]
• Protective Factors: [Strengths, supports, adaptive coping, values]

Diagnostic Impressions: [Health-related psychological/behavioral factors affecting a medical condition; other diagnoses if relevant; specify if provisional] (Include codes if required by policy.)

Stage of Change: [Precontemplation / Contemplation / Preparation / Action / Maintenance] (Brief rationale.)

Prognosis: [Brief statement addressing modifiable vs non-modifiable factors and expected response to intervention]

Standardized Measures: [Measure name: score, severity band, clinical interpretation; notable item responses] (Include only if measures were administered.)

Treatment Plan

Problem 1: [Behavioral/psychological factor affecting the medical condition]

• Goal(s): [Specific, measurable targets linked to medical outcomes; timeframe]
• Interventions Provided Today: [Psychoeducation; motivational interviewing; CBT/ACT strategies; behavioral activation/activity pacing; sleep intervention; relaxation/biofeedback; communication skills; care coordination]
• Patient Actions: [Home practice—what, when, how often; tracking method; anticipated barriers]
• Ongoing Plan: [Planned sessions/frequency; additional modules or referrals; criteria for treatment modification]

Problem 2: [Additional factor]

• Goal(s): [As above]
• Interventions Provided Today: [As above]
• Patient Actions: [As above]
• Ongoing Plan: [As above]

(Add or remove problem sections as needed; prioritize by urgency and impact on medical care.)

Coordination: [Communication with referring/medical team; referrals placed or recommended; care team updates]

Disposition & Follow-Up

• Disposition: [Routine outpatient follow-up / urgent referral / ED or higher level of care]
• Next Appointment: [Timeframe; modality; with whom]
• Safety Instructions: [Crisis resources provided; after-hours contact; instructions if symptoms worsen]
• Billing/Service Details: [Service type; time; coding elements] (Include only if required by policy.)

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