Developmental-Behavioral Pediatrics Consultation Note

Header Block

Date of Service: [Date of service]   |   Location: [clinic / telehealth]   |   Patient Name: [Patient name]   |   DOB: [Date of birth]   |   Age: [Age]   |   MRN: [Medical record number]

Parent/Guardian Present: [Name(s) and relationship(s)]   |   Others Present: [Names and roles/relationships, including remote participants]

Preferred Language: [Preferred language]   |   Interpreter: [used / not used] [Interpreter ID if used]

Referring Clinician: [Referring clinician name, credentials, practice]   |   Date of Referral: [Referral date]

Consultation Question(s): [Referral question(s) in referrer's words when available]

Releases on File: [Permitted communication targets with dates: school, therapists, agencies]

Sources of Information

Informants:

• [Informant name – relationship – modality; note any limitations such as interpreter use, time constraints, or missing caregiver]
• [Additional informants as applicable]
• [Discrepancies between informants, if present]

Records Reviewed:

• [School records with dates: IEP/504, eligibility category, psychoeducational testing, BIP/FBA, discipline/attendance]
• [Therapy reports with dates: ST/OT/PT/ABA/mental health]
• [Medical records with dates: prior evaluations, audiology/vision, labs, imaging, specialty notes]
• [Agency/case records with dates, if applicable]

Standardized Instruments and Rating Scales:

Tool/Version	Informant	Date	Key Scores	Interpretation
[Instrument name and version]	[Informant name/role]	[Date]	[Total and relevant subscale scores]	[Brief interpretation]
[Instrument requested but not returned]	[Intended informant]	Pending	Data gap	[Follow-up plan]

Chief Concern

[Brief summary of top concerns and time course; may include direct family quote; note any immediate safety concerns if present] (1–3 sentences; use family's language when directly quoted.)

History of Present Illness

[Narrative synthesis of presenting concerns organized by relevant developmental-behavioral domains. Include onset, trajectory, triggers, setting specificity, and functional impact on learning, peer relationships, family functioning, and daily living. Summarize prior interventions and response. Include family goals and definition of success.] (Use clear attribution throughout: "parent reports," "teacher form indicates," "per IEP dated." Address domains as relevant to referral: attention/executive function, emotional/behavior regulation, social communication, language/communication, restricted interests/repetitive behaviors/sensory profile, adaptive skills, motor concerns. If key data are missing for an expected domain, include a data gap statement with follow-up plan.)

Developmental History

• Prenatal/Perinatal: [Pregnancy complications, exposures, prematurity/gestational age, delivery, NICU course]
• Early Development: [Gross motor, fine motor, speech/language, social/play milestones; any regression with timing]
• Medical Developmental Modifiers: [Hearing/vision screening, seizures, sleep-disordered breathing, feeding/nutrition, head injury] (Include only if relevant.)
• Prior Developmental Services: [Early intervention, preschool special education, prior evaluations and findings]

(If milestones unknown due to adoption/foster placement, state "unknown" and note reliance on current functioning and available records.)

Medical History and Medications

• Chronic Conditions: [Conditions affecting development/behavior; hospitalizations/surgeries with dates]
• Current Medications: [Medication – dose – indication – adherence – benefit – side effects]
• Prior Medication Trials: [Medication – duration – response – reason stopped]
• Allergies: [Drug/food/environmental with reaction type]
• Relevant Testing: [Labs, imaging, genetics/metabolic with dates and results]

Family History

[Neurodevelopmental and psychiatric family history: ADHD, learning disorders, ASD, intellectual disability, language disorders, anxiety/depression, bipolar disorder, substance use, tics, seizures. Note relevant psychosocial stressors only as pertinent to care planning.] (Use bulleted format or narrative as appropriate to complexity.)

Social History

• Household/Custody: [Composition, relationships, guardianship]
• Language/Cultural Factors: [Primary language(s), cultural considerations relevant to evaluation and recommendations]
• Trauma/Adversity: [Neutral, source-attributed summary] (Include only if clinically relevant.)
• Daily Routines: [Screen time, sleep routines, extracurricular activities]
• Strengths and Interests: [Child's strengths, interests, supportive relationships, protective factors]
• Community Supports/Barriers: [Transportation, insurance, school engagement, service access]

Educational History

Current Placement

[Grade, school, district, classroom type; IEP or 504 status with eligibility category; related services and minutes; accommodations]

Academic Functioning

[Reading, writing, math performance; homework completion and work production; testing behaviors]

Behavior and Social Functioning

[Classroom behavior/regulation; peer relationships; bullying concerns; disciplinary actions; attendance; BIP/FBA status and summary]

School Evaluations

[Summary of psychoeducational testing: test names, dates, key standard scores, and concise interpretation across cognitive, academic, language, adaptive, and behavioral domains] (Provide high-yield synthesis; avoid copying verbatim.)

Teacher Input

[Narrative synthesis of teacher observations and rating scale results with attribution to specific teachers] (If teacher data not received, document as missing with follow-up plan.)

Therapies and Services

• [Therapy type – provider – frequency – goals – response] (Include ST, OT, PT, feeding therapy, ABA/behavioral services, psychotherapy as applicable.)
• [Barriers to access and care coordination resources]

Review of Systems

(Targeted to developmental-behavioral concerns; include only items addressed.)

• Sleep: [Onset, maintenance, snoring, daytime sleepiness]
• Appetite/Feeding: [Selectivity, nutritional adequacy]
• Elimination: [Constipation, encopresis, enuresis]
• Neurologic: [Headaches, seizures, tics]
• Mood/Anxiety/Irritability: [Pertinent findings]
• Safety: [Elopement, self-harm statements, unsafe behaviors]

Physical Examination

• Vitals/Growth: [Height, weight, BMI with percentiles; BP/HR if obtained]
• General Appearance: [Objective descriptors]
• Dysmorphology: [Findings] (Include only if relevant.)
• HEENT: [Pertinent findings] (Include only if relevant.)
• Neuromotor: [Tone, strength, coordination, gait, fine motor]
• Exam Limitations: [Telehealth, cooperation, or time constraints] (State explicitly if applicable.)

Behavioral Observation

[Objective description of behaviors observed during the visit: social engagement and eye contact, reciprocity, shared enjoyment; communication including speech clarity, pragmatics, nonverbal communication, response to name; play skills and flexibility; attention and activity level; emotional regulation; repetitive or sensory behaviors; parent–child interaction patterns.] (Link observations to multi-setting data; do not diagnose from observation alone.)

Assessment

Clinical Synthesis: [Integrated summary across settings and informants; developmental context; comorbidity considerations; functional impairment; consistency or discordance across sources]

Data Limitations: [Missing information or pending data affecting diagnostic confidence; plan to obtain]

Diagnostic Impressions: (Order by: safety/medical risk, highest functional impairment, family priorities.)

• [Problem 1]: [Diagnostic label] – [confirmed / provisional / rule-out]
  • Supporting Evidence: [Symptoms, impairment, settings; cite specific data sources]
  • Differential Considerations: [Alternative or overlapping explanations]
  • Etiologic Workup: [Rationale for genetic/metabolic testing] (Include for developmental delay/ID.)
• [Additional problems as applicable with same structure]

Recommendations

(Prioritize actionable steps; specify responsible party and timeframe for each.)

• Safety Planning: [Elopement prevention, aggression management, crisis resources] (Include only if indicated.)
• Medical Evaluation/Management: [Referrals, labs, medication recommendations with monitoring plan and side-effect counseling]
• Behavioral/Parent Interventions: [Parent training programs, behavior strategies, routines, reinforcement approaches]
• School Supports: [Clinical recommendations to inform IEP/504 team: accommodations, classroom strategies, FBA/BIP, related services, assistive technology; note if report will be shared per ROI]
• Therapy Referrals: [ST, OT, PT, social skills, CBT, executive function coaching]
• Community Resources: [Advocacy organizations, respite, care coordination, family support]

(Document shared decision-making discussions when multiple reasonable options exist.)

Care Coordination

[Communications completed or planned: with whom, ROI status, what was/will be sent; next coordination steps and responsible party]

Follow-up

• Timeframe/Modality: [Follow-up interval; in-person / telehealth]
• Pre-visit Items: [Teacher forms, updated IEP/504, therapy progress notes, new testing to bring or submit]
• Return Precautions: [When to contact clinic or seek urgent care for behavioral/safety escalation]

Time Statement

Total clinician time on date of service: [X] minutes (includes record review, history, examination/observation, scoring and interpretation, counseling/education, documentation, and care coordination).

(Omit this section if billing by medical decision-making complexity.)

Signature

[Electronic signature], [Credentials]