Identifying Information
- Age, grade, ethnicity, language (English 1st?), handedness
Reason for Referral
- Referral source, diagnosis, clinical complaints
Relevant History
- Birth/Dev history
- Family/Social history
- Medical history (dysmorphology/genetic testing, current or past meds, hearing/vision, surgeries/hospitalizations, neuroimaging/EEG, neurological examination findings, specific noteworthy events or episodes)
- Educational history (performance, services, academic/learning difficulties)
- Previous psych history
- Previous evaluations
- Other past interventions
Behavioral Observations
- Orientation/Attention
- Regulation of Behavion
- Social Relatedness
- Mood/Affect
- Physical features
- Responses to testing environment
- Response to Structure, ability to work full duration of testing
- Response to reinforcement strategies, stresses?
- Effort/Motivation (reliable/valid?)
- Language (Expressive: Prosody, tone, rate, word finding, fluency, syntax; Receptive: Comprehension of instructions and items)
- Visual-Perception/Construction skills
- Fine/gross motor; handwriting; hand dominance; unusual movements
Test Results
- IQ, Adaptive Fx
- Achievement
- Attn/Executive Fx/Processing Speed
- Language
- Sensory-Perceptual-Motor-Visual (primary sensory and motor functioning)
- Learning/Memory
- Behavior/Emotion/Social Cognition