Climate change is expected to reduce water availability in the Mediterranean region and water management needs to adapt to future conditions. The aims of this study were (1) to develop a participatory approach for identifying and evaluating management options for river basin climate adaptation and (2) to apply and evaluate the approach in four case-study river basins across the Mediterranean. As part of the approach, a diverse group of stakeholders joined a series of workshops and consultations in four river basins located in Cyprus, Slovenia, Spain and Tunisia. In each river basin, stakeholders expressed their views on challenges in their river basins, as well as options to tackle these challenges. We used the information on challenges, as well as the factors contributing to these challenges to develop a fuzzy cognitive map for each basin. These maps were converted into mathematical models and were used to assess the impact of a total of 102 suggested management options for the four river basins. We linked the options and their estimated impacts with a multi-criteria analysis to identify the most preferred options. The approach was positively evaluated by the participating stakeholders and allowed the link of stakeholders' knowledge and perceptions about their river basin with their preferences for options to adapt the management of their river basins to future conditions.