Neuropsychology Intake/Clinical Interview Note

Date of Service: [Date of service]

Patient Name: [Patient full name]

DOB: [MM/DD/YYYY]

MRN: [Medical record number]

Visit Type: [pre-testing intake interview / neurobehavioral status exam interview]

Modality: [in-person / video / phone]

Evaluating Neuropsychologist: [Name, credentials]

Other Participants: [Trainees present; interpreter and language if used; collateral informants with name and relationship]

Interview Time: [Start–stop times and/or total duration]

Referral Information

Referring Provider/Service: [Name, role/service, organization, referral date]

Referral Question: [Referrer's stated question] (Use referrer's phrasing when available.)

Operational Neuropsychological Questions: [Translational questions to be addressed via testing] (Restate as measurable cognitive/functional questions.)

Intended Use of Results: [clinical care / academic planning / disability determination / capacity evaluation / legal-forensic / other]

Decisions to be Informed: [diagnostic clarification / functional capacity assessment / treatment planning / baseline measurement / return-to-work or school / accommodations / other]

Informed Consent

Consent Status: [Obtained from patient / Obtained from parent / Obtained from legal guardian / Obtained from surrogate / Assent with surrogate consent / Not obtained] (If capacity is uncertain or part of the referral, state basis for assent vs. consent and identify substitute decision-maker.)

Consent Elements Reviewed: [Nature and purpose of evaluation; time commitment; third-party involvement; limits of confidentiality; communication of results]

Observers/Recording: [No observer present / Observer present with identity and reason] [No recording / Audio recording / Video recording / Recording requested and declined per policy] (If observers or recording occurred, note potential effects on standardization and mitigation steps taken.)

Sources of Information

• Patient Interview: [Yes] (Note language used and interpreter if applicable.)
• Collateral Interview(s): [Name, relationship, contact method, date] (Omit if none obtained.)
• Records Reviewed: [List by type and date, e.g., neurology note MM/DD/YY, MRI report MM/DD/YY, prior neuropsych report with date and setting]

Reliability of Information: [Reliability statement] (Anchor to observed factors such as cognitive impairment, emotional distress, language barriers, limited historian, inconsistent recall, or concordance across sources. Avoid conclusory labels.)

Presenting Concerns

Chief Concern: [Brief description with patient quote if it clarifies phenomenology]

Onset and Course: [Onset timing; pattern: progressive / stepwise / fluctuating; precipitating events if any]

• Attention/Processing Speed: [Symptoms and functional impact]
• Learning and Memory: [Encoding, retention, retrieval issues; real-world examples]
• Language/Word-Finding: [Expressive or receptive difficulties; word-finding; paraphasias]
• Executive Functions: [Planning, organization, flexibility, inhibition, problem-solving, multitasking]
• Visuospatial/Construction: [Navigation, spatial judgment, drawing, assembly tasks]
• Motor/Sensory: [Weakness, tremor, numbness, coordination, gait]
• Mood/Anxiety/Trauma: [Current symptoms relevant to cognition]
• Sleep/Fatigue/Pain: [Sleep quality, apnea risk, daytime sleepiness, fatigue pattern, pain severity]

(Include only domains with reported symptoms.)

Safety Screening: [Suicidal ideation denied or present / Homicidal ideation denied or present / Self-harm denied or present] (If positive, document severity, plan, intent, protective factors, and actions taken.)

Background History

(Use concise bullets with dates. For clinically relevant information not obtained, use status terms: Denied, Unknown, Not assessed with reason, or Unavailable today with plan to obtain.)

Medical/Neurological

• [Major diagnoses with dates and current status]
• [Head injuries: number, severity markers, LOC/PTA, dates]
• [Stroke/TIA, seizures, CNS infections, sleep disorders, chronic pain, endocrine/metabolic conditions]
• [Sensory impairments and assistive devices]
• [Relevant imaging and labs summary with dates]

Psychiatric

• [Prior diagnoses with dates]
• [Treatment history: therapy, psychiatry, hospitalizations, response]
• [Current symptoms that could confound testing]

Developmental/Educational

(Include when pediatric evaluation or when ADHD/LD/ASD is part of the differential.)

• [Pregnancy/birth complications; developmental milestones; early language/motor]
• [Highest education level, degrees, language of instruction]
• [Learning disorder/ADHD history; special education/IEP/504; grade repetition; literacy]

Occupational/Functional Baseline

• [Work history; military service]
• [Disability or leave status]
• [Baseline independence before symptom onset]

Family History

• [Dementia, stroke, seizures, learning disorders, major psychiatric illness, substance use disorders in first-degree relatives]

Social/Psychosocial

• [Living situation; primary supports; caregiver stress]
• [Major stressors; legal involvement if relevant to referral]
• [Cultural or linguistic factors affecting test selection]
• [Strengths and protective factors]

Substance Use

• [Alcohol: pattern, quantity, longest sobriety, last use, treatment history]
• [Cannabis, stimulants, opioids, sedatives, tobacco/nicotine, other substances]
• [Current use vs. remission with duration]

Medications

• [Current medications with dose, frequency, indication]
• [PRNs and recent medication changes]
• [OTCs and supplements with potential cognitive impact]

(If medication list unavailable, note plan to reconcile before testing.)

Prior Evaluations & Records

• [Prior neuropsychological evaluations: dates, setting, broad findings] (Do not include raw scores or test items.)
• [Cognitive screeners: name, date, overall impression]
• [Imaging impressions, EEG, sleep study, pertinent labs with dates]
• [Records requested but not yet received]

Functional Status

• ADLs: [Bathing, dressing, toileting, feeding, mobility: independent vs. assistance needed]
• IADLs: [Finances, medications, cooking, shopping, transportation, appointments, technology: current abilities and supports]
• Work/School Functioning: [Attendance, productivity, errors, accommodations, leave or disability status]
• Driving: [Current status; accidents or near misses; getting lost; family concerns]
• Supervision: [Level of oversight and caregiver involvement]

Behavioral Observations & Mental Status

Appearance/Behavior: [Grooming, dress, eye contact, psychomotor activity, cooperation, engagement, rapport, frustration tolerance]

Communication/Language: [Speech rate and volume; articulation; comprehension; word-finding; need for repetition; tangentiality; hearing or vision issues]

Mood/Affect/Thought: [Patient-described mood; observed affect with range and congruence; thought process; thought content abnormalities; perceptual disturbances]

Cognition (informal): [Alertness; orientation; attention; memory for recent events; insight and judgment as observed] (If a brief screener was administered, document name and overall impression only.)

Validity-Relevant Observations: [Fatigue; pain behaviors; environmental issues; inconsistent effort indicators] (Frame as potential limitations on testing conditions rather than attributing intent.)

Clinical Formulation

• [Provisional conceptualization summarizing key findings from history and observations]
• [Working differential diagnoses] (Use tentative language: suggests, may reflect, consider.)
• [Key supporting features and counterpoints]
• [Confounds and limitations: language proficiency, sleep deprivation, acute stress, sensory deficits, substances, pain]
• [Medical necessity rationale for testing beyond existing information]

Assessment Plan

• Planned Cognitive Domains: [Attention/processing speed; learning/memory; language; executive functions; visuospatial; motor/sensory; academic skills] (Tailor to referral questions. Validity will be assessed as standard practice.)
• Rating Scales/Questionnaires: [Self-report and informant measures planned]
• Accommodations/Modifications: [Testing language; interpreter plan; sensory/motor accommodations; session splitting; break schedule; optimal time of day]
• Additional Records Needed: [Outstanding records to obtain before testing]
• Feedback & Communication Plan: [Planned feedback session; communication with referrer]
• Safety/Urgent Referrals: [Immediate referrals or follow-up actions required]

Time & Service Documentation

Total Interview Time: [Minutes]

Activities Included: [Face-to-face interview; review of records; collateral contact; documentation]

Signature: [Electronic signature]

Credentials: [Degree, license]

Date/Time Signed: [MM/DD/YYYY HH:MM]