Informed consent for the pre-operative bariatric psychological evaluation, covering evaluation scope, information sharing with the surgical team, and patient acknowledgments.
The Bariatric Psychological Evaluation Consent is a ready-to-use healthcare & wellness template you can send for signature in minutes. It is written for 1 signer (patient) and, by default, expires 30 days after it is sent if left unsigned. It covers consent, bariatric, psychological evaluation, mental health, pre operative. Like every Abundera Sign template it is a convenience draft structured for ESIGN Act and UETA compliance, not a substitute for legal advice. Each signed copy is sealed with PAdES-LTA digital signatures, dual RFC 3161 timestamps, and a tamper-evident evidence package in WORM storage.
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# Bariatric Psychological Evaluation Consent > **Important — not medical advice.** For use by a licensed provider; tailor to the patient, your protocols, and state law. **Patient Name:** ___________ **Date of Birth:** ___________ **Evaluation Date:** ___________ **Evaluating Clinician:** ___________ **Bariatric Program / Referring Surgeon:** ___________ --- ## 1. Purpose of This Evaluation A pre-operative psychological evaluation is a required component of the multidisciplinary bariatric clearance process for weight-loss surgery programs. The evaluation is not a test with a pass/fail outcome; its purpose is to: - Assess psychological readiness for bariatric surgery and the significant lifestyle changes required for long-term success. - Identify psychiatric conditions that may affect surgical outcomes or that would benefit from treatment before or after surgery (e.g., untreated depression, eating disorders, substance use, trauma history). - Assess understanding of the procedure, its risks, and the lifelong behavioral changes required. - Identify support systems and psychosocial stressors that may affect recovery. - Provide recommendations to the bariatric surgical team regarding timing, additional pre-operative support, or post-operative follow-up. --- ## 2. What the Evaluation Includes The evaluation typically involves: - A structured clinical interview covering psychiatric history, current mental health status, eating behaviors, substance use, weight history, motivation, and social support. - Standardized psychological questionnaires (examples: PHQ-9 for depression, AUDIT for alcohol use, BES for binge eating, AUDIT-C, BDI, or others as selected by the evaluating clinician). - Review of relevant medical and psychiatric records (if available and consented separately). **Estimated duration:** ___________ ---