Rehabilitation Psychology Intake Assessment (Biopsychosocial)

Date of Service: [Date]   Patient Name: [Full name]   DOB: [MM/DD/YYYY]   MRN: [MRN]
Author/Credentials: [Name, credentials]   Setting: [inpatient rehab / acute care consult / outpatient]
Participants Present: [Patient and others present with roles]   Reason for Evaluation: [new admission / consult request / pre-treatment evaluation / other]

Referral Information

[Referral source and service] — [Stated referral reason or question]. [Patient-stated goals] (Include patient goals only if available and relevant to rehabilitation.)

Sources of Information

(Omit this section if evaluation is straightforward with no reliability concerns.)

[Sources used: patient interview, caregiver, chart review, prior reports, standardized measures]. [Reliability considerations] (e.g., aphasia, delirium, cognitive impairment, interpreter-mediated interview, limited historian). [Key history not obtained and plan to obtain] (Include only if applicable.)

Chief Concern

[Presenting problem in 1–2 sentences] (Use patient's own words when meaningful, especially for safety-related statements. If patient cannot provide, note alternate source and reason.)

History of Present Illness and Rehabilitation Context

[Integrative narrative summarizing: injury/illness diagnosis, onset, mechanism, and acuity; rehabilitation course including surgeries, complications, and current therapies; current symptoms impacting rehabilitation such as pain, fatigue, sleep, cognitive complaints, and emotional distress; psychological response to illness/injury including adjustment, fear avoidance, grief, identity disruption, or trauma response; beliefs about recovery, goals, and readiness for change.] (Link symptoms explicitly to functional impact on therapy participation, safety, and discharge planning. Reference medical H&P rather than duplicating details not essential to psychological formulation.)

Background History

(Include only subsections that inform current care; omit those that do not apply.)

Psychiatric and Behavioral Health History

• [Prior diagnoses and symptom patterns with approximate timeframes]
• [Past treatments: therapy modalities, psychiatric medications, response, adherence, hospitalizations/ED visits]
• [Self-harm/suicide history: ideation, attempts, NSSI] — [Denies / Unknown / Not assessed]
• [Relevant trauma/adversity history] (Document if patient declines to discuss.)
• [Family psychiatric history] (Include only if clinically relevant.)

Substance Use

• [Substances used: alcohol, cannabis, stimulants, opioids (prescribed/non-prescribed), sedatives, tobacco/nicotine, other] — [Pattern, quantity/frequency, last use, withdrawal risk]
• [Treatment history]
• [Impact on mood, cognition, safety, or rehabilitation participation]

Psychosocial History

• [Living situation and supports; caregiver availability and burden]
• [Education and vocational status; employment/disability/leave]
• [Financial or legal stressors relevant to care] (Include only if applicable.)
• [Cultural/spiritual factors affecting care]
• [Strengths and resources: coping skills, community supports, motivation]

Current Functional Status

(Use baseline → current format where helpful; quantify assistance levels and tolerance when possible.)

• Body functions/impairments: [Pain interference, sleep, fatigue, attention/memory, emotion regulation]
• Activity limitations: [ADLs, mobility, medication management, communication] (Specify assistance level: independent / supervision / minimal assist / moderate assist / maximal assist / total assist.)
• Participation restrictions: [Work/school, parenting, driving, social activities]
• Contextual factors: [Home accessibility, caregiver support, financial strain, coping style, health literacy, cultural considerations]
• Safety-relevant function: [Falls risk behaviors, judgment concerns, inability to meet basic needs, medication errors] (Highlight discharge-relevant barriers.)

Mental Status Examination

• Behavioral observations: [Engagement, cooperation, effort, distress tolerance, pain behaviors, impulsivity, agitation, safety awareness]
• Appearance: [Description]
• Psychomotor: [Description]
• Speech: [Rate, volume, fluency]
• Mood: [Patient-reported]
• Affect: [Range, congruence, stability]
• Thought process: [coherent / linear / goal-directed / tangential / circumstantial / disorganized]
• Thought content: [SI/HI, delusions, obsessions] (Use direct quotes for pivotal safety statements.)
• Perceptions: [Hallucinations or none reported]
• Cognition: [Orientation, attention, memory, processing speed, executive function] (Note aphasia, hearing/vision limitations, or elements unable to assess with reason.)
• Insight and judgment: [Description]

Standardized Measures

(Omit this section entirely if no measures were administered.)

• [Tool name] — [self-report / interview] — [Score and interpretation] — [Limitations/modifications] — [Reviewed with patient: yes / no]

Risk Assessment

(This section is required. Use direct quotes for pivotal safety-related statements.)

Suicide/Self-Harm Risk

• Current status: [Ideation: none / passive / active] — [Plan] — [Intent] — [Preparatory behaviors] — [Access to lethal means]
• History: [Past attempts, NSSI, relevant hospitalizations]
• Risk factors: [Acute stressors, substance use, hopelessness]   Protective factors: [Social supports, reasons for living]
• Risk level: [low / moderate / high] — Rationale: [Key factors supporting determination]
• Mitigation plan: [Actions taken, safety plan status and location, monitoring plan, crisis resources provided]

Violence/Aggression Risk

• Current status: [Thoughts of harm to others, targets, intent/plan, access to weapons]
• History and contributors: [Prior violence, impulsivity, psychosis, substance factors]
• Risk level: [low / moderate / high] — Rationale: [Key factors]
• Mitigation plan: [De-escalation strategies, environmental measures, notifications]

Safety and Self-Care

• Capacity: [ADLs/iADLs, medication safety, delirium-related risks, vulnerability to abuse/neglect/exploitation]
• Risk level: [low / moderate / high] — Rationale: [Key factors]
• Mitigation plan: [Safeguards, caregiver involvement, team notifications, follow-up timeframe]

Clinical Formulation

[Integrative summary linking medical/rehabilitation context, psychological/behavioral presentation, functional impact on rehabilitation, and key barriers and facilitators.] (Write 3–6 sentences synthesizing the case.)

Problem List: (Organize by rehabilitation priority.)

• Problem 1: [Name] — Evidence: [Symptoms/observations/measures] — Functional impact: [Effect on therapy participation/safety/discharge] — Maintaining factors: [Cognitive/behavioral/contextual] — Protective factors: [Strengths/resources]
• (Add additional problems as needed.)

Diagnostic Impression: [Primary diagnosis(es)] — [Differential considerations or provisional diagnoses] (Label provisional diagnoses clearly.) — [Historical diagnoses and current status]

Treatment Plan and Recommendations

(Organize by target problem; align goals to rehabilitation outcomes.)

• Target Problem: [Name]
  • Functional goal(s): [Concrete goals tied to participation/discharge]
  • Interventions: [e.g., CBT-based coping skills, motivational interviewing, behavioral activation, relaxation training, pain coping, caregiver coaching]
  • Follow-up: [Frequency and expected duration]
  • Measurement: [Outcomes tracked and frequency]

Team Recommendations: [Guidance for rehabilitation team: cueing strategies, reinforcement approaches, education modifications, accommodations for cognitive/communication barriers, environmental or schedule adjustments]

Referrals/Consults: [Psychiatry / neuropsychological testing / social work / chaplaincy / pain service / substance treatment / community resources] (Include only if indicated.)

Risk-Related Actions: [Who was notified, safeguards initiated, safety plan location, follow-up timeframe] (Include only if elevated risk identified.)

Disposition and Follow-Up

• Disposition: [Continue rehab psychology / PRN / discharge from service]
• Next contact: [Scheduled date/time or trigger for earlier contact]
• Patient/family communication: [Summary of plan discussed]
• Team communication: [Information shared with interdisciplinary team]
• Caregiver involvement: [Education/coaching/follow-up plan] (Include only if applicable.)

Electronic Signature: [Name, Credentials, Date/Time]