Copyable Bariatric Psychological Evaluation Template
A bariatric psychological evaluation helps the surgical team understand a patient’s mental health history, eating behaviors, coping skills, expectations, and readiness for the demands of bariatric surgery. The note should be clear enough for the referral source, clinically useful for treatment planning, and specific enough to support the recommendation being made.
The template below is designed for behavioral health clinicians who complete pre-surgical bariatric evaluations. Adapt it to your setting, referral requirements, payer expectations, and clinical judgment.
Bariatric Psychological Evaluation Template
Client Name: [Client full name]
Date of Birth: [MM/DD/YYYY]
Date of Evaluation: [MM/DD/YYYY]
Evaluator: [Clinician name, credentials]
Referral Source: [Surgeon, bariatric program, primary care provider, self-referral]
Type of Surgery Being Considered: [Gastric sleeve, gastric bypass, revision, other]
Reason for Evaluation: [Client] was referred for a pre-surgical psychological evaluation as part of the bariatric surgery clearance process. The purpose of this evaluation is to assess psychological readiness, mental health history, eating patterns, behavioral risk factors, support system, understanding of post-operative expectations, and any recommendations that may support surgical preparation and long-term adjustment.
Sources of Information: Clinical interview with [client], review of available records from [source], completed questionnaires or screening tools including [list tools if used], and collateral information from [source, if applicable].
Presenting Concerns and Weight History
Current Weight and BMI, if provided: [Document information provided by medical team or client. Avoid calculating if outside your role or if data is unavailable.]
Weight History: [Describe onset of weight concerns, periods of weight gain or loss, prior weight management efforts, and factors that affected weight changes.]
Previous Weight Loss Attempts: [Include diets, medications, exercise programs, medically supervised programs, therapy, support groups, or prior surgery.]
Motivation for Surgery: [Describe client’s stated reasons, such as health conditions, mobility, quality of life, family role, or medical recommendation.]
Medical and Psychiatric History
Relevant Medical History: [List relevant medical conditions reported by the client or referral source, such as sleep apnea, diabetes, hypertension, chronic pain, mobility limitations, or other concerns.]
Current Medications: [List psychiatric and non-psychiatric medications if clinically relevant and available.]
Mental Health History: [Document history of depression, anxiety, trauma, bipolar disorder, psychosis, ADHD, eating disorders, substance use concerns, prior therapy, psychiatric hospitalization, self-harm, or suicidal ideation.]
Current Mental Health Symptoms: [Describe mood, anxiety, sleep, stress level, trauma symptoms, body image concerns, impulse control, emotional regulation, and current safety concerns.]
Risk Assessment: Client [denies/reports] current suicidal ideation, homicidal ideation, self-harm behavior, or psychotic symptoms. [Include details, protective factors, risk level, safety planning, referrals, or emergency recommendations as clinically indicated.]
Eating Behavior and Lifestyle Assessment
Current Eating Patterns: [Describe meal frequency, grazing, night eating, binge episodes, emotional eating, restrictive patterns, skipping meals, eating speed, and awareness of hunger/fullness cues.]
Disordered Eating Concerns: [Document presence or absence of binge eating, purging, laxative misuse, compulsive exercise, loss-of-control eating, or other clinically relevant patterns.]
Substance Use: [Describe alcohol, cannabis, nicotine, prescription medication misuse, illicit substances, caffeine, and history of substance use treatment if relevant.]
Physical Activity and Daily Functioning: [Document current activity level, barriers to movement, work schedule, caregiving demands, pain, mobility, and realistic behavior-change opportunities.]
Understanding of Bariatric Surgery
Knowledge of Procedure: [Describe client’s understanding of the surgery, expected benefits, possible risks, dietary changes, follow-up care, and need for long-term behavior change.]
Expectations: [Document whether expectations appear realistic. Include client’s goals, timeline expectations, and understanding that surgery requires ongoing medical, nutritional, and behavioral follow-up.]
Adherence Readiness: [Assess readiness to follow dietary recommendations, attend appointments, take supplements if prescribed, monitor symptoms, and communicate with the care team.]
Psychosocial Factors and Support
Living Situation: [Describe household, stability of housing, caregiving responsibilities, and post-operative recovery environment.]
Support System: [Identify supportive family, friends, partner, peer group, bariatric support group, therapist, or care team members.]
Stressors: [Document work stress, financial concerns, relationship conflict, grief, trauma, transportation barriers, food insecurity, or other factors that may affect preparation or recovery.]
Coping Skills: [Describe current coping strategies, emotional regulation skills, problem-solving ability, and openness to support.]
Mental Status Examination
Appearance and Behavior: [Describe presentation, hygiene, eye contact, psychomotor activity, and engagement.]
Speech: [Rate, rhythm, volume, clarity.]
Mood and Affect: [Client-reported mood and observed affect.]
Thought Process and Content: [Logical, goal-directed, tangential, ruminative, delusional content, preoccupations.]
Perception: [Hallucinations or perceptual disturbance denied/reported.]
Cognition: [Orientation, attention, memory, concentration.]
Insight and Judgment: [Clinical impression.]
Clinical Impressions and Recommendations
Diagnostic Impressions: [List diagnoses if appropriate, or state that diagnosis is deferred. Include relevant codes only if they are part of your documentation process.]
Summary of Findings: [Provide a concise clinical summary of strengths, concerns, readiness factors, and any barriers that need attention before or after surgery.]
Recommendation: Based on the information available at this evaluation, [client] appears to be [an appropriate candidate / an appropriate candidate with recommendations / not currently ready pending further treatment or stabilization] from a psychological perspective. This recommendation is based on [specific clinical reasons]. Final surgical decisions remain with the bariatric surgery team and medical providers.
Recommended Supports: [Examples: continue individual therapy, begin therapy for emotional eating, attend bariatric support group, complete nutrition education, monitor mood symptoms, address substance use, coordinate with prescriber, follow up in 30–90 days.]
Evaluator Signature: [Name, credentials, license number if used in your setting]
Completed Bariatric Psych Eval Sample
This sample is fictional and for documentation training only. It shows the level of detail many clinicians aim for without turning the evaluation into an overly long narrative.
Client: Maria R., age 42
Date of Evaluation: 04/18/2026
Referral Source: Bariatric surgery program
Procedure Being Considered: Gastric sleeve
Reason for Evaluation: Maria was referred for a pre-surgical psychological evaluation as part of the bariatric surgery preparation process. The evaluation focused on psychological readiness, mental health history, eating behaviors, expectations, support system, and recommendations for post-operative adjustment.
Weight and Health History: Maria reported a long history of weight concerns beginning in adolescence, with more significant weight gain after pregnancy and during a period of night-shift employment. She reported previous attempts at calorie tracking, commercial diet programs, walking plans, and medically supervised nutrition visits. She stated that she has been considering surgery for two years due to knee pain, fatigue, and concerns about diabetes risk. Medical history reported by the client includes hypertension, sleep apnea, and chronic knee pain.
Mental Health History: Maria reported a history of major depressive episodes in her 20s and intermittent anxiety related to work and family stress. She attended outpatient therapy for six months after a divorce and described it as helpful. She denied psychiatric hospitalization, suicide attempts, current suicidal ideation, homicidal ideation, or psychotic symptoms. She reported occasional low mood when pain limits activity but denied current symptoms consistent with severe depression. She is not currently in therapy and does not take psychiatric medication.
Eating Behavior: Maria described a pattern of skipping breakfast, eating a quick lunch at work, and eating larger portions in the evening. She reported emotional eating two to three times per week, usually after stressful workdays. She denied purging, laxative misuse, or compensatory exercise. She reported two episodes in the past month in which she felt a loss of control while eating snack foods at night. She expressed willingness to work with the dietitian on structured meals and slower eating.
Substance Use: Maria denied tobacco or illicit drug use. She reported alcohol use approximately one to two drinks per month and denied history of substance use treatment.
Understanding and Expectations: Maria demonstrated a basic understanding of gastric sleeve surgery, including the need for smaller meals, protein intake, vitamin supplementation if prescribed, and routine medical follow-up. Her expectations appeared generally realistic. She stated, “I know this is not a quick fix. I need help sticking with the changes.” She identified improved mobility and health as her primary goals rather than a specific clothing size or weight number.
Support and Stressors: Maria lives with her adult daughter, who has agreed to help during the immediate recovery period. She also identified one close friend who had bariatric surgery and is willing to attend support meetings with her. Current stressors include work demands, knee pain, and limited time for meal preparation. She reported stable housing and reliable transportation.
Mental Status Examination: Maria arrived on time and was cooperative throughout the interview. Appearance was appropriate. Speech was normal in rate and volume. Mood was described as “hopeful but nervous,” with congruent affect. Thought process was logical and goal-directed. No hallucinations, delusions, suicidal ideation, or homicidal ideation were reported or observed. She was alert and oriented. Insight and judgment appeared fair to good.
Clinical Impression: Maria presents with a history of depression and current mild anxiety related to surgery and lifestyle change. She demonstrates realistic expectations, adequate understanding of surgery requirements, and a stable support system. Emotional eating and inconsistent meal structure are relevant behavioral targets.
Recommendation: Maria appears to be an appropriate candidate from a psychological perspective with recommendations. Recommended supports include continued nutrition education, participation in a bariatric support group, and brief therapy focused on emotional eating, stress coping, and post-operative adjustment. Coordination with the bariatric team is recommended if mood symptoms worsen or adherence concerns emerge.
When to Use a Bariatric Psych Eval Template
Use this type of template when a client is referred for psychological assessment before bariatric surgery or revision surgery. Many bariatric programs request documentation that addresses mental health stability, eating behavior, readiness for post-operative changes, and the client’s ability to participate in follow-up care.
A structured template is especially helpful when evaluations are infrequent in your practice. It reduces the chance of missing key areas, such as substance use, prior eating disorder symptoms, unrealistic expectations, or limited support after surgery.
It can also help when multiple clinicians in a group practice complete these evaluations. Consistent headings make the notes easier to review and compare, while still allowing each clinician to write individualized clinical impressions.
What a Strong Bariatric Psych Eval Should Capture
A useful bariatric evaluation does more than state that the client is “cleared” or “not cleared.” It should explain the clinical reasoning behind the recommendation. Surgical teams need to understand the client’s strengths, risk factors, and support needs.
Readiness for behavior change: Document the client’s understanding of dietary changes, follow-up appointments, activity expectations, and long-term self-monitoring. Readiness does not mean perfection. It means the client has enough awareness, support, and willingness to engage with the treatment plan.
Mental health stability: Describe current symptoms, treatment history, risk concerns, and protective factors. A history of depression, anxiety, trauma, or disordered eating does not automatically mean a client is not ready. The evaluation should focus on current functioning, stability, insight, and support.
Eating behavior patterns: Include emotional eating, binge eating, grazing, night eating, restriction, purging behaviors, and meal structure. Be specific. “Client reports emotional eating after conflict with partner two to three evenings per week” is more useful than “poor eating habits.”
Support and barriers: Post-operative recovery can be affected by transportation, work schedules, caregiving duties, finances, food access, pain, and relationship stress. Naming these factors helps the team plan realistic supports.
Common Mistakes to Avoid
Using a generic mental health intake without bariatric-specific sections. A standard intake may document depression, anxiety, trauma, and family history, but miss surgery knowledge, post-operative expectations, eating patterns, and adherence readiness.
Writing a recommendation without clinical reasoning. If the note says the client is appropriate for surgery, explain why. If you recommend therapy, support groups, or follow-up before surgery, connect the recommendation to the findings.
Overstating certainty. Psychological evaluations are based on available information, clinical interview, records reviewed, and the client’s self-report. Use measured language, especially when discussing readiness, risk, and prognosis.
Ignoring strengths. Many notes focus only on risk factors. Document protective factors too, such as stable housing, insight, prior success with behavior change, family support, consistent medical follow-up, or willingness to attend counseling.
Quick Checklist Before Finalizing the Evaluation
Before signing the note, review whether the evaluation answers the referral question and gives the bariatric team clear next steps.
- Does the note describe the client’s understanding of the surgery and required lifestyle changes?
- Does it address current and past mental health symptoms, risk, and treatment history?
- Does it include eating behaviors, substance use, support system, and barriers to follow-up?
- Does the recommendation match the clinical findings and include practical supports if needed?
If a section is unknown, document that clearly rather than leaving it blank. For example: “Records from the bariatric program were not available at the time of evaluation” is more useful than omitting sources of information.
How AutoNotes Helps With Bariatric Psych Eval Documentation
Bariatric psychological evaluations can take longer than standard progress notes because they combine clinical interview, behavioral assessment, risk review, mental status exam, and a written recommendation. AutoNotes helps clinicians create structured, editable drafts from session details, so the note starts organized instead of blank.
For this type of evaluation, AutoNotes can help you draft sections such as reason for referral, weight and eating history, mental health history, risk assessment, mental status exam, clinical impression, and recommendations. You remain responsible for reviewing, editing, and finalizing the note based on your clinical judgment and the requirements of the referral source.
Compared with a generic AI writing tool, AutoNotes is built around behavioral health documentation. That means the output is organized for clinical use, not just general writing. You can keep the structure consistent across evaluations while tailoring the language to each client.
If bariatric evaluations are part of your practice, saving even a few minutes on each section can make the documentation process easier to manage. The goal is not to remove clinician review. The goal is to give you a clearer first draft and reduce the after-hours writing burden.
Start your free trial to create structured, editable clinical documentation drafts for evaluations, progress notes, treatment plans, and other behavioral health services.
