Learning Difficulties and School Functioning Consultation Note

Date: [Date] | Patient: [Full name] | DOB: [DOB] | Encounter Type: [in-person / video]

Location: [Clinic/site] | Referring Provider: [Name, credentials] | Consult Question: [Primary consultation question]

Information Sources and Reliability

Informants: [Parent/guardian / Patient / Teacher report / Other] (List all; attribute by name/role when provided.) ; Interpreter: [Yes (language) / No] (Omit if not applicable.) ; Records reviewed: [List documents with dates] (Omit if none available.) ; Reliability: [Good / Fair / Limited] (Comment on consistency across sources.)

Consent and Information Sharing

• Release of Information (ROI) for school communication: [on file / requested today / declined / unknown] (If unknown, note planned action to confirm/obtain.)
• Scope/permissions: [Evaluation findings / Recommendations / Medications / Attendance / Other] (Specify what may be shared.)
• Authorized school contacts: [Names/roles/organization]
• Records requested from school: [IEP / 504 plan / Evaluation reports / Progress monitoring / Report cards / Attendance / Behavior records / Work samples] (Select all that apply.)

Chief Concern and Functional Impact

[Presenting concern described in school-functional terms] (One concise paragraph linking the concern to impacts on academic progress, homework independence, classroom behavior, and emotional well-being. Include family goals and the child/adolescent perspective when developmentally appropriate. Optionally include a brief salient quote.)

Educational History

• Current placement: [Grade] ; [School type: public / private / charter / homeschool] ; [Classroom setting: general education / inclusion / special education / other]
• Attendance: [Typical pattern / Absences / Tardiness] (Include timeframe.)
• Retention/acceleration: [Year(s) and rationale] (Omit if none.)
• School mobility: [Transfers with dates and context] (Omit if not relevant.)

Academic Skills by Domain

(Address only domains relevant to the referral. If a domain lacks information but is central to the referral, note that formal assessment is recommended. Omit domains with no available information.)

• Reading: [Decoding / Fluency / Comprehension] — [Strengths]; [Concerns]; [Observable examples]
• Writing: [Handwriting / Spelling / Written expression] — [Strengths]; [Concerns]; [Observable examples]
• Math: [Calculation / Word problems / Fluency] — [Strengths]; [Concerns]; [Observable examples]
• Oral language: [Expressive / Receptive / Pragmatics] — [Strengths]; [Concerns]; [Observable examples]
• Learning behaviors: [Work completion / Test-taking / Organization of materials] — [Strengths]; [Concerns]; [Observable examples]

Executive Functioning Observations

• Organization/planning: [Description]
• Task initiation/sustained attention: [Description]
• Working memory demands: [Description]
• Homework routine: [Duration / Independence / Adult scaffolding / Environment]

Behavioral, Social, and Emotional Factors

• Classroom behavior: [Behaviors impacting participation]
• Peer relationships: [Strengths / Concerns]
• Emotional factors: [Anxiety / Mood / Avoidance / Somatic complaints]
• Disciplinary history: [Detentions / Suspensions / Office referrals with dates/context] (Omit if none.)
• Safety concerns (if present): [Self-harm statements / Aggression / Elopement] — [What occurred]; [Who was notified]; [Disposition] (Omit entire field if no safety concerns.)

School Supports

• Current plan status: [None / 504 plan / IEP / Plan in development] — [Source: parent report / confirmed by documents dated (date)] (Do not state a plan exists unless confirmed by documents or clearly attributed to informant.)
• IEP details (if applicable):
  • Eligibility category: [As documented]
  • Services: [Type; frequency; duration; delivery model (push-in / pull-out / consult)]
  • Goal themes: [High-level areas; do not copy verbatim]
  • Related services: [SLP / OT / PT / Counseling / Other]
  • Key accommodations: [List]
• 504 plan details (if applicable):
  • Accommodations: [Major categories]
  • Implementation concerns: [Fidelity / Barriers] (Omit if none.)
• Prior interventions and response: (Chronological; omit categories with no history.)
  • [RTI/MTSS tier and duration; response]
  • [Reading/math intervention or tutoring; response]
  • [Therapies (SLP/OT/etc.); response]
  • [Medication trials with school-observed effects]

Prior Testing

(If family reports prior testing but no report is available, note this and avoid relying on unverified specifics. Omit entire section if no prior testing.)

• Evaluation reports available: [Evaluator type / Setting / Date / Reason for evaluation]
• Tests administered: [List measures] (Note validity/effort concerns if documented.)
• Summary of results:
  • Cognitive profile highlights: [Qualitative interpretation; include key scores only if they inform recommendations]
  • Academic achievement by domain: [Reading / Writing / Math]
  • Language measures: [Receptive / Expressive]
  • Behavior rating scales: [Elevations by rater/domain]
  • Evaluator conclusions: [Diagnoses / School eligibility determinations]

Medical and Developmental Context

(Include only history relevant to learning and school functioning.)

• Early communication milestones: [Milestones; speech therapy history]
• Motor/handwriting development: [Fine/gross motor concerns]
• Sleep: [Schedule / Duration / Quality / Snoring / Sleep disorder symptoms]
• Hearing and vision: [Screening status/results; follow-up needed]
• Neurologic history: [Seizures / Head injury / Other] (Omit if not relevant.)
• Current medications: [Medications affecting cognition/attention/sleep]

Mental Health and Neurodevelopmental History

• ADHD symptoms: [Inattention / Hyperactivity-Impulsivity; impairment across settings]
• Anxiety/depression symptoms: [Impact on school engagement]
• ASD-related features: [Social communication; Restricted/repetitive behaviors affecting classroom function] (Omit if not relevant.)
• Trauma/stressor history: [Brief, non-graphic description] (Omit if not relevant.)
• Prior diagnoses and treatments: [Diagnoses; therapies/medications and response]

Family and Social Context

(Include when relevant to learning.)

• Family history: [Learning disorders / ADHD / Anxiety / Other]
• Home language and cultural context: [Language exposure; evaluation considerations]
• Access barriers: [Transportation / Cost / Scheduling] (Omit if none identified.)

Examination and Observations

• Vitals and growth: [Height / Weight / BMI / BP / Pulse] (Include especially for medication management; otherwise omit.)
• Behavioral observations: [Attention to conversation / Activity level / Frustration tolerance / Language pragmatics / Effort and rapport / Anxiety signs]
• Mental status: [Appearance / Behavior / Speech / Mood/affect / Thought process/content / Insight/judgment] (Include for adolescents or when clinically indicated.)
• Exam limitations: [Video constraints / Cooperation / Time] (Omit if exam was not limited.)

Assessment

(Ranked problem list with most impairing concerns first. Each problem includes one to two lines of supporting evidence. Do not infer a confirmed learning disorder without appropriate evaluation data.)

1. [Problem 1]: [Brief description of impairment and key supporting evidence]
2. [Problem 2]: [Brief description of impairment and key supporting evidence]

(Add or remove problems as appropriate.)

Diagnostic Impressions

• Confirmed diagnoses: [DSM diagnoses with adequate supporting evidence] (Omit if none confirmed.)
• Suspected conditions requiring evaluation: [e.g., rule out specific learning disorder in (domain); ADHD; language disorder]
• School eligibility categories: [As documented in school records] (Do not infer eligibility.)
• Differential considerations: [Language difference vs learning disorder vs inadequate instruction; ADHD vs sleep disorder vs anxiety-related inattention]

Plan

[Summarize shared decision-making with family, emphasis on collaboration with school, and what additional data are needed.]

[Problem 1]

• Formulation: [Brief explanation of what we think is happening]
• Evaluation recommended: [School-based / Medical] — [Academic achievement / Cognitive processing / Speech-language / OT / Social-emotional / Classroom observation / Assistive technology / FBA] (Specify recommended vs optional.)
• Immediate actions: [Accommodations tied to functional limitation / Interventions / Strategies / Medication changes]
• Monitoring: [Progress data to track; timeframe; who will collect]

[Problem 2]

• Formulation: [Brief explanation]
• Evaluation recommended: [As above, tailored to problem]
• Immediate actions: [As above]
• Monitoring: [As above]

(Add or remove problem sections as needed.)

Accommodation Categories to Consider

(Select and tailor to patient's functional limitations. Prioritize most impactful; do not include exhaustive lists.)

• Instruction/delivery: [Previewing; multi-sensory instruction; small-group reteaching]
• Work output/assessment: [Alternate formats; reduced length; extended time]
• Environment/pacing: [Preferential seating; movement breaks; chunking]
• Executive function supports: [Checklists; planner support; visual schedules]
• Reading supports: [Audiobooks; text-to-speech]
• Behavioral supports: [Positive reinforcement; home-school communication]
• Health access: [Nurse access; medication administration; hydration/snack]

Referrals and Coordination

• [Referral type] — [Purpose and urgency] (Include only referrals being placed.)
• Forms/letters completed: [Letter to school / Medication authorization / Other]
• Rating scales sent: [Vanderbilt / Conners / BASC / BRIEF / Other] — [Raters; due date]
• Records requested: [From school / Prior evaluators / Primary care]

Follow-Up

• Return: [Timeframe tied to next expected data]
• Bring to next visit: [IEP/504 documents; teacher input; work samples; progress monitoring data; rating scale results]