Initial Evaluation (Sports Psychology)

Date: [Encounter date]

Time: [Start time] – [End time] ([Total duration])

Clinician: [Name, credentials, role, organization/team affiliation]

Patient: [Name], [Sport/discipline], [Position/role], [Competitive level: youth / high school / college / professional / elite], [Current season phase]

Modality: [In-person / video / phone]; [Location/site]

Participants Present: [List all present: athlete, parent/guardian, coach, athletic trainer, interpreter, others]

Data Sources: [Athlete self-report / collateral informants / prior records / standardized measures] (Specify each source used and attribute data elements throughout the note.)

Referral and Service Framework

Referral Source and Reason: [Referral source] — [Stated reason for referral] (Include organizational context if applicable, e.g., embedded in athletics department, EAP, private practice.)

Scope of Service: [Performance consultation / mental health treatment / integrated model] (State what services are included and excluded; specify whether diagnoses will be assigned and whether return-to-play opinions are provided.)

Informed Consent: [Method: written / electronic / verbal]; [Elements consented to: interview, screening tools, collateral contact, coordination] (For minors, document parent/guardian consent and athlete assent separately.)

Confidentiality and Information Sharing: [Standard limits discussed: imminent risk, abuse/neglect reporting, court orders] — [Client of record: athlete / organization] — [Information sharing agreement with team/organization] — [Crisis communication plan] — [Releases of information on file: recipients and scope]

Third-Party Involvement: [Payer or requesting party] — [Constraints: session limits, reporting requirements] (If not applicable, omit this field.)

Consent/Confidentiality Status: [Completed / not completed] (If not completed, document reason and plan to complete.)

Presenting Concerns and Goals

Chief Concern: [Chief concern in athlete's words] (Use direct quote when clinically useful.)

Concern Classification: [Performance-related / mental health / adjustment-transition / relationship-system / mixed]

History of Presenting Concern: [Onset and course] — [Triggers and maintaining factors] — [Severity and contextual variability] — [Prior interventions attempted] — [Athlete's understanding of causes] (Attribute to athlete, collateral, or records as applicable.)

Impact on Functioning: [Performance impact] — [Mental health impact] — [Social/academic/occupational impact] — [Safety concerns if any]

Athlete-Defined Goals: [Short-term goals] — [Season/career goals] — [Observable indicators of progress] — [Readiness for change] — [Perceived barriers] (If goals not fully defined, note plan to refine.)

Sport and Performance Context

Sport Identity and Participation: [Sport/discipline] — [Role/position] — [Competitive level] — [Years in sport] — [Specialization history] — [Recent transitions]

Training Load and Recovery: [Typical weekly volume and intensity] — [Recent changes] — [Strength/conditioning and skill work] — [Recovery practices] — [Overtraining or under-recovery concerns]

Competitive Environment: [Competition schedule density] — [Travel demands] — [Selection/roster pressures] — [Scholarship/contract considerations] — [Media or sponsorship demands] — [Injury/return-to-play pressures and timelines]

Team and System Factors: [Coaching style and communication] — [Team culture and psychological safety] — [Conflicts or maltreatment concerns] (Document factually without investigative conclusions.)

Performance History and Routines: [Prior peak performances and supporting conditions] — [Recent significant events] — [Pre-competition, in-competition, and post-performance routines]

Mental Skills Baseline

(Include when performance is a focus of evaluation. If acute clinical stabilization takes priority, document deferral and rationale below.)

• Attention and Focus: [Current patterns and situational variability]
• Arousal Regulation: [Under-/over-arousal tendencies and current strategies]
• Confidence and Self-Efficacy: [Patterns, contingencies, stability]
• Perfectionism: [Adaptive and maladaptive features]
• Imagery/Visualization: [Current use, quality, controllability]
• Self-Talk: [Content, flexibility, cueing]
• Emotion Regulation: [Strategies for coping with errors and adversity]
• Motivation and Sport Identity: [Intrinsic/extrinsic drivers, values alignment]
• Performance Routines: [Pre-/in-/post-competition routines and recent changes]
• Skills Status: [Skills currently used / previously taught / avoided or not yet learned]

Deferral Status: [Completed / deferred] (If deferred, document reason and plan to complete.)

Psychosocial and Developmental History

• Living Situation and Relationships: [Household composition, key relationships] — [Quality of support system] — [Relationship stressors affecting sport]
• Education/Work: [Program/role] — [Schedule and demands] — [Accommodations or disability services]
• Cultural Identity and Context: [Identity factors athlete considers important] — [Experiences of belonging or discrimination affecting functioning]
• Trauma or Harm Indicators: [Athlete's report] — [Observed signs] — [Actions taken] — [Mandated reporting steps if applicable] (Document factually; do not draw investigative conclusions. Omit if not indicated.)

Medical and Mental Health History

• Medical Conditions and Injuries: [Current and past conditions] — [Injury history including concussion/TBI, chronic pain, surgeries] — [Current rehabilitation status and restrictions]
• Medications and Supplements: [Current medications including psychotropics] — [Adherence and performance-relevant side effects] — [Supplements and ergogenic aids]
• Substance Use: [Caffeine/energy drinks, nicotine/vaping, alcohol, cannabis, stimulants, other] (Include frequency, context, and impact on performance/sleep.)
• Past Mental Health History: [Prior diagnoses and treatment episodes] — [Hospitalizations or crisis visits] — [Prior self-harm or suicide attempts] — [What helped or hindered in past treatment] — [Family psychiatric history] (If not assessed, document reason.)
• Nutrition and Body Considerations: [Eating patterns, body image concerns, energy availability] — [Menstrual history if applicable] (Include for weight-sensitive sports or when clinically indicated.)

Standardized Measures

(Document tools administered. Use table format for multiple measures.)

Tool	Method	Date	Score	Interpretation
[Tool name and version]	[Self-report / clinician-administered]	[Date]	[Score/range]	[Brief clinical interpretation]

Measures Deferred: [Reason for deferral] — [Plan to complete] (Omit if all planned measures completed.)

Mental Status Examination

• Appearance and Behavior: [Description]
• Psychomotor Activity: [Within normal limits / increased / decreased]
• Speech: [Rate, volume, tone]
• Mood: [Athlete's subjective report]
• Affect: [Range, intensity, appropriateness, stability]
• Thought Process: [Coherent and goal-directed / tangential / circumstantial / other]
• Thought Content: [Performance-related cognitions, worries, themes; SI/HI screening results]
• Perception: [Within normal limits / abnormalities noted] (Include only if assessed.)
• Cognition: [Orientation, attention, memory as indicated]
• Insight and Judgment: [Description]
• Reliability: [Good / fair / limited] (Include basis if limited.)

Risk Assessment and Safety

• Suicide/Self-Harm Screening: [Ideation: present / absent] — [Intent, plan, means access] — [Behaviors or preparatory acts] — [Past attempts/self-harm] — [Protective factors and reasons for living] — Risk Level: [Low / moderate / high] with [rationale]
• Violence/Harm to Others: [Threats, intent, plan, access, history, protective factors] (Omit if not indicated.)
• Abuse/Neglect/Safeguarding: [Disclosure details] — [Mandated reporting decision and actions] — [Safety steps taken] (Omit if not indicated.)
• Medical Risk Behaviors: [Sport-relevant concerns: dietary restriction, dangerous weight-cutting, training against medical advice] — [Education and referrals provided] (Omit if not indicated.)
• Safety Interventions: [Safety plan: completed / not indicated] — [Crisis resources provided] — [Emergency referral if applicable] — [Follow-up timeframe]

Risk Screening Status: [Completed / not completed] (If not completed, document reason and immediate mitigation.)

Clinical Impression and Formulation

[Integrative summary in 3–6 sentences connecting presenting concerns, sport demands and timing, key contributors, functional impact, and strengths] (Include statement of medical necessity for evaluation and recommendations.)

Formulation:

• Predisposing Factors: [Factors]
• Precipitating Factors: [Factors]
• Perpetuating Factors: [Factors]
• Protective Factors: [Strengths and supports]
• Performance-Specific Mechanisms: [e.g., attentional narrowing, threat appraisal, routine disruption]

Diagnostic Impression: [Working diagnosis / differential diagnoses with supporting and contradicting evidence] (If diagnosis deferred, specify information needed. If performance consultation only, state: "No DSM diagnosis assigned; performance consultation service.")

Key Strengths and Barriers: [Strengths: support, motivation, prior coping success] — [Barriers: sleep, travel, stigma, limited support]

Plan and Recommendations

Athlete Preferences and Focus: [Agreed focus areas] — [Education provided] — [Resources or handouts given]

Problem-Oriented Plan: (Prioritize by risk or impact.)

• Problem 1: [Problem name]
  • Target Outcomes: [Observable outcomes]
  • Interventions: [Skills training, CBT/ACT, exposure, sleep intervention, communication strategies, other]
  • Between-Session Practice: [Homework or field practice]
  • Monitoring: [Measure or behavioral indicator]
  • Coordination/Referrals: [Recipients, information to share, releases on file]
• Problem 2: [Additional problems as applicable with same structure]

Risk Management: [Crisis plan] — [Emergency resources provided] — [Safety plan: completed / copy provided to athlete: yes / no] (Omit if no risk identified.)

Care Coordination: [Releases on file and scope] — [Information to be shared, with whom, by whom] — [Follow-up tasks and responsible parties]

Disposition: [Next appointment: date/time or scheduling plan] — [Level of care: routine outpatient / other recommendation]

(Attribute information to source throughout. Use neutral, behaviorally anchored language. For consent, confidentiality, and risk screening: if not completed, document reason and plan rather than omitting. Do not infer consent, confidentiality review, or risk screening if not documented in the encounter.)