Personal Injury/Psychological Damages Evaluation Report

(Use "examinee" or "evaluee" rather than "patient" unless a treatment relationship exists. Attribute every clinically or legally important assertion to its source: examinee self-report, treatment records, collateral interview, test results, investigative materials. Present contested facts as claims with attribution, not as established fact. Use explicit date format YYYY-MM-DD for incidents, symptom onset, treatment, and evaluation dates. Maintain clear separation between observed/measured data, clinical inferences/interpretations, and ultimate opinions; use signposting language to distinguish these levels. Core forensic sections must always appear: Referral Context and Scope, Sources of Information, Procedures, Validity Considerations, Opinions, Limitations. For other sections, omit entirely if irrelevant; if included but information is unavailable, state "Not assessed," "Not provided," or "Not available" and note implications for conclusions. Do not opine outside the stated referral scope; if potentially relevant issues arise outside scope, note them without rendering an opinion.)

Report Identification

Report Title: Personal Injury / Psychological Damages Evaluation Report

Case Caption: [Court/venue, parties, docket number] (Use exact styling provided by counsel.)

Examinee: [Full name] | DOB: [Date of birth] | Evaluation date(s): [Evaluation date(s)] | Location: [Evaluation location] | Modality: [in-person / remote] (Specify platform if remote.)

Retaining Party (Client): [Name] | [plaintiff counsel / defense counsel / neutral / court-appointed] | [Contact information]

Examiner: [Name, degree] | License: [License number(s) and jurisdiction(s)] | [Practice address] | [Board certifications]

Executive Summary

(Provide a concise overview for the trier of fact. Begin with a framing statement such as: "The following opinions are based on the information reviewed and procedures described in this report; limitations are noted where information was unavailable." Offer 3–10 numbered or bulleted conclusions.)

• [Primary diagnosis(es) or "No diagnosis supported"] (Specify current vs. historical vs. provisional.)
• [Key functional impairments] (Briefly describe main domains affected and severity.)
• [Causation opinion with qualifiers] (State standard used if provided; otherwise note clinical-forensic terms.)
• [Validity/credibility summary statement] (Response style, symptom/performance validity, overall interpretability.)
• [Prognosis] (If addressed.)
• [Treatment needs/future care overview] (If within scope.)
• [Apportionment/contribution summary] (If requested; acknowledge limits of precision.)

Referral Context and Scope

Referral source: [Requesting party name and role] (Identify retaining party as the client; distinguish clearly from the examinee.)

Referral questions: [Verbatim questions as provided] (Common topics: diagnosis/differential, causation/contribution, functional impact and work capacity, need for future treatment, validity assessment.)

Causation standard: [Jurisdictional standard provided / Not provided] (If not provided, note that opinions are offered in clinical-forensic terms for the trier of fact to map to the applicable legal standard.)

Scope limitations: [Matters explicitly outside scope] (Do not opine beyond this scope.)

Forensic Advisement and Consent

[Documentation of forensic nature explanation] (State that this is a forensic evaluation; no therapeutic relationship exists; the retaining party is the client.)

[Purpose and anticipated uses explained] | [Report recipients identified] | [Limits of confidentiality in litigation explained] | [voluntary / court-ordered] participation | [Right to consult counsel explained]

[Informed consent obtained / Court order reviewed; notice provided] on [Date] | Cooperation: [cooperation level] | Third-party observers: [none / present—identity and role] | Recording: [none / audio / video—by whom]

Sources of Information

(List all materials reviewed. For each document or source, provide type, source/author, date range, and date received. Identify which sources were most relied upon for key opinions. If essential records were unavailable, specify what was requested, what was received, and how the absence limits conclusions.)

• Documents reviewed:
  • [Document type] | [Source/author] | [Date range] | Received: [Date received]
  • (Repeat as needed for each document.)
• Collateral interviews:
  • [Name] ([Relationship to examinee]) | [Date] | [phone / video / in-person] | [Duration]
  • (Include contact attempts if no interview obtained.)
• Most relied-upon sources for key opinions: [Sources and the opinions they primarily support]
• Unavailable/missing records: [Requested items not received] | [Follow-up attempts and dates] | [Impact on conclusions]

Procedures Performed

Evaluation date(s) and times: [Date(s) with start–stop times] | Total contact time: [Duration]

Time allocation: Clinical interview: [Duration] | Psychological testing: [Duration] | Record review: [Duration] | Collateral contacts: [Duration] (Include report preparation time only if required by disclosure rules.)

Interview methods: [unstructured / structured / semi-structured] (Name specific instruments if used.)

Psychological tests administered: [Test names and versions] (Include reason for selection and administration conditions; note accommodations or deviations from standard administration.)

Behavioral observations: [Appearance, cooperation, effort, persistence, distress tolerance, comprehension, notable inconsistencies] (Describe observed behaviors only; do not infer intent.)

Claimed Injuries and Index Event(s)

Claimed psychological injuries: [Each claimed condition/symptom with source attribution: examinee report / attorney correspondence / treating clinician diagnosis]

Index event(s): (Provide neutral, source-attributed narrative for each event; list separately if multiple.)

• [Event description] | [Date] | Source(s): [records / depositions / examinee / other]
• (Repeat for additional events.)

Symptom timeline: Onset: [immediate / delayed—specify interval]; Course: [Course and fluctuations]; Treatment response: [Response to treatment with dates] (Attribute to sources and note discrepancies.)

Relevant History

Pre-incident psychiatric/psychological history: [Prior diagnoses, treatment episodes, hospitalizations, trauma history, baseline functional impairment] (Source-attributed; note absence of corroborating records if applicable.)

Post-incident psychiatric/psychological course: [Diagnoses, treatments, hospitalizations, therapy modalities, adherence, response with dates]

Relevant medical history: [Chronic pain, TBI, sleep disorders, neurologic/endocrine or other conditions affecting mood/cognition] (Include medications with potential psychological effects.)

Substance use: [Substance type(s); quantity/frequency; onset/changes post-incident; treatment history]

Developmental, educational, and occupational history: [Highest education; work history; baseline occupational functioning and performance]

Social supports and stressors: [Family, relationships, housing, financial/legal stressors] (Include prior litigation/claims only if materially relevant.)

Current treatment providers and regimen: [Provider names/roles; modalities; medications; adherence; side effects if relevant]

Current Clinical Findings

Current symptoms by domain: (Include severity, frequency, duration, and functional consequences for each. Source-attribute.)

• Mood/Depression: [Symptoms and parameters]
• Anxiety/Panic: [Symptoms and parameters]
• Trauma-related: [Intrusions, avoidance, arousal, negative cognitions]
• Sleep disturbance: [Onset/maintenance difficulties, nightmares, restorative quality]
• Irritability/Anger: [Triggers, frequency, impact]
• Cognitive complaints: [Attention, memory, processing speed, executive function]

Mental Status Examination:

• Appearance and behavior: [Observed findings]
• Speech: [Rate, volume, prosody]
• Mood and affect: [Stated mood; observed affect—range, congruence]
• Thought process and content: [Coherence, associations; delusions/obsessions if present]
• Cognition: [Orientation; attention/concentration; gross memory; insight; judgment]
• Safety assessment: [Suicidal ideation: present / denied] [Homicidal ideation: present / denied] (Document actions taken if safety concerns identified.)

Psychological Testing

(Include only if testing was performed. Do not reproduce proprietary test items. Reference appropriate handling procedures for raw data if production is requested.)

Tests administered: [Full test names and versions; rationale for selection]

Administration conditions: [Setting; breaks; accommodations; deviations from standard protocols]

Norms and scoring: [Normative samples used; scoring approach]

Validity and response style: [Symptom validity indicators—over/under-reporting; performance validity if cognitive testing; internal consistency findings]

Interpretability statement: [Results are considered valid and interpretable / Results require caution due to validity concerns—specify which conclusions are affected]

Key scores/results:

• [Measure name]: [Score/Index/T-score/Percentile] | [Interpretive range]
• (Repeat as needed; include only scores necessary to support conclusions.)

Narrative interpretation: [Integration of results with diagnostic support, differential diagnosis, and functional implications] (Differentiate test data from clinical inference.)

Validity Considerations

(Address validity even if no formal testing was performed. Synthesize observations, response style, consistency across sources, and corroboration status.)

• Consistency of presentation: [Degree of consistency across interviews, records, and collateral sources]
• Effort and engagement: [Observed effort; effects of pain, fatigue, language, or cultural factors]
• Secondary gain context: [Potential influences and how addressed in interpretation]
• Overall validity conclusion: [Summary statement and impact on confidence in findings]

Diagnostic Formulation

(Provide DSM/ICD diagnoses; specify current vs. historical vs. provisional. Briefly map symptoms and duration/impairment to criteria without reproducing criteria verbatim. Discuss differential diagnosis, comorbidity, and how overlapping symptoms were adjudicated.)

• Diagnoses: [Diagnosis] — [current / historical / provisional] (Repeat for each diagnosis, or state "No diagnosis supported.")
• Rationale: [Salient symptoms, duration, impairment; source attribution]
• Differential diagnosis: [Plausible alternatives; reasoning for acceptance/rejection]
• Comorbidity considerations: [How overlapping symptoms were adjudicated]

Causation Analysis

(Restate the causation question. Analyze baseline functioning, temporal relationship to index event(s), plausible mechanisms, and alternative etiologies. Compare examinee report with contemporaneous records, collateral, and testing; identify material inconsistencies and their effect on confidence. Provide qualitative apportionment if requested and feasible.)

• Causation question: [Verbatim or as provided by counsel]
• Pre-incident baseline: [Functioning and symptoms; evidence summary; uncertainties due to missing records]
• Temporal relationship: [Index event date(s) and symptom onset/course]
• Plausible mechanism: [Clinical pathway linking event to condition]
• Comparative source analysis: [Agreements/discrepancies across records, collateral, testing; impact on confidence]
• Alternative etiologies and pre-existing factors: [Prior trauma, pre-existing conditions, chronic pain, substance use, concurrent stressors; relative contributions]
• Conclusion on contribution of index event: [caused a new condition / aggravated a pre-existing condition / triggered recurrence / not supported as a substantial contributor] (Provide rationale.)
• Apportionment: [Qualitative/quantitative apportionment with rationale; acknowledge limits of precision] (If requested.)

Functional Impact

(Compare pre-incident to post-incident functioning. Tie each limitation to specific symptoms, observed behavior, test findings, or treatment record evidence. If work capacity opinions are requested, specify essential job demands affected and distinguish restrictions from limitations.)

• Occupational function: [Attendance; productivity; stress tolerance; interpersonal demands; safety-sensitive tasks]
• Activities of daily living: [Self-care; household management; community functioning]
• Social/interpersonal functioning: [Family; peers; conflict; withdrawal]
• Sleep and energy: [Duration/quality; daytime fatigue]
• Cognitive efficiency: [Concentration; decision-making; processing speed]
• Recreation and quality of life: [Hobbies; enjoyment; participation]
• Work capacity: [Restrictions (should not do) vs. limitations (cannot do); duration and conditions] (If requested.)

Prognosis and Future Care

(If within scope. Address expected duration and trajectory with factors affecting outcome. Recommend evidence-based treatment options with rationale, intensity, and duration assumptions. If future damages support is requested, provide clinical need and expected frequency; avoid cost calculations unless specifically within scope.)

• Prognosis: [favorable / guarded / poor] — [Basis and key modifiers]
• Recommended treatments: [Modalities; frequency; duration; rationale] (Adherence considerations and likely benefit.)
• Maintenance/relapse prevention: [Follow-up needs and contingencies]

Opinions

(Number opinions to correspond to referral questions. For each, provide the conclusion, a brief basis with key supporting facts and data, and confidence qualifiers with limitations. Use jurisdiction-requested certainty language if provided. If an opinion cannot be reached, state so and identify information that would increase confidence.)

1. Opinion 1: [Conclusion] | Basis: [Key supporting facts/data with source attribution] | Confidence/limitations: [Certainty language; constraints]
2. Opinion 2: [Conclusion] | Basis: [Key supporting facts/data] | Confidence/limitations: [Qualifiers]
3. (Add additional opinions as needed to address each referral question.)

Limitations

(Address factors constraining reliability and validity. Explain how each limitation impacts specific conclusions.)

• [Limitation and its impact on conclusions]
• (Common limitations: missing records especially pre-incident baseline, reliance on self-report with corroboration status, time elapsed since incident, secondary gain context, test validity concerns and affected conclusions, cultural/language factors, evaluation constraints.)

Attestation and Signature

I declare under penalty of perjury that the opinions stated herein are based on my education, training, and experience; the information reviewed and procedures described; and are offered to a reasonable degree of [psychological / neuropsychological / clinical / forensic] certainty unless otherwise qualified. I reserve the right to supplement this report if additional information becomes available.

Signature: ___________________________

[Name, degree] | License: [Number(s) and jurisdiction(s)] | [Board certifications] | Date signed: [Date]

Attachments:

• Curriculum vitae
• Test battery list (names only)
• Referenced exhibits/record index
• Expert disclosure elements per court rule: publications (past 10 years), prior testimony (past 4 years), compensation statement (Include as required by applicable rules.)