Integrated Psychological Evaluation Report (US)
Report Template:
A US report template for psychological evaluation and testing, supporting CPT 96130 and 96131 written for third-party recipients. A formal integrated psychological evaluation report that supports CPT codes (96130, 96131) related to evaluation and testing services conducted by licensed mental health professionals (clinical psychologists, psychiatrists, and psychiatric nurse practitioners/ARNPs) for third party recipients (other providers, educational professionals, insurance payers/third party administrators, or legal/occupational). It synthesizes information from NovoNote and NovoPsych psychometrics, integrating session notes, contextual notes, psychometric results and collateral information into a full, coherent, psychodiagnostic assessment and evaluation. It covers history, current functioning, mental status, risk, functional impairment, clinical/medical history, clinical formulation, diagnostic impressions, clinical assessments administered, with relevant documented impairment, medical necessity, and a section on recommendations as stated by clinician and supported in the clinical narrative. It may be used with evaluation service billing codes for direct patient contact, clinical data and report writing components, separate from any test administration or scoring.
Please note: While this template is intended to be broadly applicable, it is important that clinicians review outputs to confirm accuracy and ensure compliance with their specific state, organizational, governmental, legal, and ethical regulations. Because the framing of results, psychometric interpretations, and clinical recommendations can vary depending on the evaluation’s purpose and the requirements for the intended recipient, clinicians assume responsibility for the appropriate adaptations and execution of this document.
Letter Header:
Recipient’s name, title and address
Re: client’s name
DOB:
Age:
Address:
Salutation and Recipient Name
The following report summarizes evaluation type, date/date range
Purpose of Evaluation and Presenting Concerns:
- Referral source, reason for referral and referral questions
- Presenting concerns as described by the client and each informant, named by role
- Any modifications or assistive measures used during the evaluation
Information Sources:
- Each source with its date: session notes, contextual notes, clinical assessment measures, and third-party material such as school records, prior evaluations, medical records and collateral reports
- Date range the report covers
Demographics:
- Age, gender identity, sexual orientation, pronouns, ethnicity, preferred language, and cultural considerations relevant to care and to interpreting findings
Background and Developmental History:
- Early development, milestones, prenatal and perinatal factors, and early concerns
- Family structure, relationships and dynamics
- Education and employment history, including accommodations received
- Family history of medical, psychiatric and neurodevelopmental conditions
Medical Status and Medical History:
- Non-psychiatric diagnoses and medical conditions, including chronic, neurological and sleep conditions
- Reported treatment response, side effects and adverse reactions
Mental Health History:
- Prior psychiatric diagnoses, treatment and its effect, and any psychiatric hospitalizations
Medication History:
- Current and past medications with dose, frequency, response and side effects
- Deferral to the prescribing provider where the clinician is not the prescriber
Substance Use History:
- Current and past use of alcohol, nicotine, cannabis, other substances and misused prescription medication, including denials
Other Behavioral Addictions History:
- Gambling, gaming, internet or social media use, and other compulsive behaviors described in the sources
Legal History:
- Illegal activity, justice system involvement and incarceration
Trauma History:
- Adverse experiences, timing, developmental impact and coping responses
Social History:
- Living arrangements, social support, quality of relationships, religious or spiritual identity, and sociocultural context
Current Presentation and Functional Assessment:
- Current symptoms with onset, duration and course
- Stressors and interpersonal factors
- Impact on self-care, social, occupational or academic, and adaptive functioning
- Lifestyle indicators, coping strategies and strengths
Mental Status Examination:
- Brief summary based on the most recent session that records mental status
Safety and Risk Assessment:
- Suicidal and homicidal ideation, self-harm, access to lethal means, and other risk issues relevant to the evaluation
- Risk management, where documented
Clinical Assessments:
- Summary paragraph for each measure: name, description, date, purpose, full results and clinical implications
- Summary table of results (Measure, Date, Scale, Severity)
Clinical Formulation:
- Biopsychosocial formulation integrating predisposing, precipitating, perpetuating and protective factors
- Documented symptoms and functional impairment in each affected domain
- Medical necessity statement stated by the clinician
Diagnosis:
- Each diagnosis at the clinician’s stated certainty, with DSM-5-TR name and ICD-10-CM code
- Criteria met, supporting assessment results and discrepancies, differential diagnoses and contextual considerations
Recommendations:
Headings for each clinician indicated recommendation grouping
- Medication Review or Changes
- Psychological and Other Non-Pharmacological Interventions
- Referrals
- Diagnosis-Specific Recommendations
- Lifestyle Recommendations
- Workplace or Academic Modifications
- Follow-Up and Monitoring: any indicated monitoring, reassessment or risk management plans
Prognosis (only where stated by the clinician):
- Expected course, influencing factors and limits to prognostic certainty
Summary:
- Summarizes reason for evaluation, key findings, diagnoses, medical necessity and next steps
Sign off
Clinician’s name
License and credentials
Report date
Sarah Lee, MD, Primary Care Physician
25 NovoNote Avenue, Austin, TX 78701
Re: Emma Brown
DOB: 05/22/1998
Age: 28
Address: 11 NovoNote Street, Suite 200, Austin, TX 78701
Dear Dr. Lee,
The following report summarizes a comprehensive psychological evaluation of Emma Brown, conducted between September 8, 2026, and September 22, 2026.
Purpose of Evaluation and Presenting Concerns:
Emma Brown was referred by Dr. Sarah Lee, primary care physician, for evaluation of possible attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD), and to inform treatment planning and workplace accommodations. Emma reported lifelong difficulty with focus, organization and meeting deadlines, alongside social exhaustion, difficulty reading social cues and strong sensitivity to noise and change. Her mother, interviewed as a collateral informant, described similar difficulties from early childhood. Emma was offered breaks and a reduced-noise testing room during the evaluation.
Information Sources:
- Clinical interview with Emma, September 8, 2026
- Developmental history interview with Emma’s mother, September 8, 2026
- Wechsler Adult Intelligence Scale – Fourth Edition (WAIS-IV), September 15, 2026
- Autism Diagnostic Observation Schedule – Second Edition (ADOS-2), Module 4, September 15, 2026
- Ritvo Autism Asperger Diagnostic Scale – 14 (RAADS-14), September 15, 2026
- Adult ADHD Self-Report Scale (ASRS v1.1), September 15, 2026
- Wender Utah Rating Scale – 25 (WURS-25), September 15, 2026
- Generalized Anxiety Disorder-7 (GAD-7) and Patient Health Questionnaire-9 (PHQ-9), September 15, 2026
- Elementary school report cards
- Feedback session notes, September 22, 2026
Demographics:
Emma is a 28-year-old woman who uses she/her pronouns. English is her preferred language.
Background and Developmental History:
Emma’s mother reported an uncomplicated pregnancy and birth, with motor and language milestones within expected timeframes. As a child, Emma was described as a “daydreamer” who preferred solitary play, became distressed with changes in routine and covered her ears in noisy settings. School report cards from first through fifth grade noted that she was “easily distracted” and “often did not finish classwork.” Emma completed a bachelor’s degree in accounting with extended effort and has worked as a data analyst for four years. She lives with her partner. Her brother was diagnosed with ADHD in adolescence.
Medical Status and Medical History:
Emma is in good general health. She reported long-standing difficulty falling asleep, typically taking more than an hour on work nights.
Mental Health History:
Emma was diagnosed with generalized anxiety disorder by Dr. Lee at age 22 and completed individual cognitive behavioral therapy, which she described as “somewhat helpful.” She has no other prior psychiatric diagnoses or hospitalizations.
Medication History:
Emma takes sertraline 50 mg daily, prescribed by Dr. Lee, with a partial benefit for anxiety. Medication management is deferred to the prescribing provider.
Substance Use History:
Emma reported drinking alcohol socially, about two drinks per week, and up to four cups of coffee daily. She denied nicotine, cannabis or other substance use.
Other Behavioral Addictions History:
Emma reported spending several hours each evening on her phone, which she described as a way to decompress after work.
Legal History:
No legal history was reported.
Social History:
Emma has a small number of long-standing friendships and prefers one-on-one contact to group settings. She described feeling exhausted after social events and “copying” others to fit in. Her partner is her main source of support.
Current Presentation and Functional Assessment:
Emma described inattention, distractibility, forgetfulness, procrastination and difficulty starting and finishing tasks, which have led to missed deadlines and a recent performance review at work. She reported restlessness and interrupting others in meetings. Socially, she has difficulty following group conversations, interpreting indirect communication and knowing when to speak. She relies on fixed routines, becomes distressed by unexpected changes and finds open-plan office noise overwhelming. At home, she relies on her partner for bill payments and appointments. Strengths include strong attention to detail in areas of interest, honesty and persistence.
Mental Status Examination:
Emma was casually dressed, cooperative and fidgety, with reduced eye contact and flat prosody; mood was described as “stressed,” affect was mildly anxious, and thought process was logical and goal-directed.
Safety and Risk Assessment:
Emma denied suicidal ideation, self-harm and thoughts of harming others. She reported no access to firearms, and no other risk issues were identified.
Clinical Assessments:
The WAIS-IV was administered on September 15, 2026 to estimate cognitive functioning. Emma’s Full Scale IQ was 104 (61st percentile, average). Verbal Comprehension was a relative strength at 112 (79th percentile, high average), while Working Memory was 89 (23rd percentile, low average) and Processing Speed was 86 (18th percentile, low average). This pattern is consistent with attention and executive-function difficulties rather than global cognitive weakness.
The ADOS-2 Module 4 was administered on September 15, 2026 to observe social communication and restricted and repetitive behaviors. Emma obtained a Communication score of 4 and a Reciprocal Social Interaction score of 7, for a Communication + Social Interaction total of 11, in the Autism classification range. Observations included limited reciprocal conversation, reduced use of gesture and difficulty describing others’ emotions.
The RAADS-14 was completed on September 15, 2026 as a self-report screen for autism traits. Emma obtained a total score of 31, above the screening cutoff of 14, with elevations across mentalizing, social anxiety and sensory reactivity.
The ASRS v1.1 was completed on September 15, 2026 to assess current ADHD symptoms. Emma endorsed 5 of 6 Part A items in the clinically significant range, highly consistent with adult ADHD, with inattentive symptoms more prominent than hyperactive-impulsive symptoms.
The WURS-25 was completed on September 15, 2026 to assess retrospective childhood ADHD symptoms. Emma’s total score was 52, above the cutoff of 46, supporting childhood onset of symptoms.
The GAD-7 and PHQ-9 were completed on September 15, 2026 to assess co-occurring anxiety and depression. Emma scored 11 on the GAD-7 (moderate anxiety) and 8 on the PHQ-9 (mild depression).
| Measure | Date | Scale | Severity |
| WAIS-IV | 09/15/2026 | Full Scale IQ | Average; 104 |
| WAIS-IV | 09/15/2026 | Working Memory | Low average; 89 |
| WAIS-IV | 09/15/2026 | Processing Speed | Low average; 86 |
| ADOS-2 Module 4 | 09/15/2026 | Communication + Social Interaction | Autism classification; 11 |
| RAADS-14 | 09/15/2026 | Total | Above cutoff; 31 |
| ASRS v1.1 | 09/15/2026 | Part A | Highly consistent with ADHD; 5/6 |
| WURS-25 | 09/15/2026 | Total | Above cutoff; 52 |
| GAD-7 | 09/15/2026 | Anxiety | Moderate; 11 |
| PHQ-9 | 09/15/2026 | Depression | Mild; 8 |
Clinical Formulation:
Emma’s presentation reflects co-occurring neurodevelopmental differences in attention regulation and social communication that were present in childhood but not identified. Predisposing factors include a family history of ADHD and early sensory sensitivity. Increased workplace demands and an open-plan office have precipitated more visible difficulty, while social masking, poor sleep and limited supports perpetuate exhaustion and anxiety. Protective factors include average overall cognitive ability, strong verbal skills, a supportive partner and stable employment. Documented impairment includes missed work deadlines, difficulty in group social settings and reliance on others for household tasks. Given the confirmed diagnoses and impairment across work and home, outpatient behavioral health intervention and workplace accommodations are medically necessary to support Emma’s functioning.
Diagnoses:
- Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Presentation (F90.0) – new diagnosis. Six inattentive symptoms were reported across work and home, with onset before age 12 supported by school records, collateral report and the WURS-25. Anxiety was considered as a differential explanation but does not account for the childhood onset.
- Autism Spectrum Disorder, Level 1 – requiring support, without accompanying intellectual impairment, without accompanying language impairment (F84.0) – confirmed, new diagnosis. Persistent social communication differences and restricted, repetitive patterns of behavior were evident on the ADOS-2, RAADS-14 and developmental history. Social anxiety was considered as a differential.
- Generalized Anxiety Disorder (F41.1) – confirms an earlier diagnosis, considered secondary to unsupported neurodevelopmental differences.
Recommendations:
Medication Review or Changes:
- Referral to Dr. Lee for consideration of ADHD medication evaluation, given impairment across settings.
Psychological and Other Non-Pharmacological Interventions:
- Cognitive behavioral therapy adapted for adult ADHD, focused on planning, organization and task initiation.
- Autism-affirming psychoeducation to support self-understanding and reduce masking-related exhaustion.
Workplace or Academic Modifications:
- Workplace accommodations, including written instructions, a quieter workspace or noise-canceling headphones, flexible deadlines and advance notice of changes.
Follow-Up and Monitoring:
- Repeat ASRS v1.1 and GAD-7 in three months to monitor symptoms and response to supports.
Prognosis:
Prognosis is favorable given Emma’s average cognitive ability, stable employment, supportive partner and motivation for treatment, with improvement expected as intervention and workplace supports are put in place.
Summary:
Emma Brown was referred for evaluation of possible ADHD and autism to clarify diagnosis and guide treatment and workplace support. Findings from interview, collateral report, observation and standardized measures showed lifelong inattention and social communication differences affecting work and home, with relative weaknesses in working memory and processing speed. Emma meets criteria for ADHD, Predominantly Inattentive Presentation (F90.0), and Autism Spectrum Disorder, Level 1 (F84.0), with co-occurring Generalized Anxiety Disorder (F41.1). Outpatient behavioral health intervention and workplace accommodations are medically necessary given documented impairment. Recommended next steps include medication evaluation, ADHD-adapted therapy, autism-affirming psychoeducation and workplace accommodations.
If you have any questions about the contents of this report, please feel free to contact me.
Yours sincerely,
Dr. Laura Smith, Ph.D.
Licensed Psychologist, Texas LP# 12345
Report Date: 10/1/2026
- Template Type
- Report
- Letter
Author:
Dr Liz Rojas
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