Parent/Guardian Interview Summary (Evaluation)

Date/Time: [Date and time of interview]

Location/Modality: [clinic / telehealth / school / home]; [in-person / video / phone]

Clinician: [Clinician name and credentials]

Patient: [Child name and identifiers]

(This note documents caregiver-reported history only. Do not include objective testing findings or final assessment/formulation. Attribute information to its source using "caregiver reports," "per school records," or "clinician interpretation" as appropriate. For missing information, document "Unknown" or "Not assessed" with reason. Use neutral, behavior-based language throughout.)

Informants & Communication

• Informants: [Names and relationships to child] (State whether each informant lives with the child [Yes / No / Partial] and whether the child was present during the interview [Yes / No].)
• Source reliability/limitations: [Overall reliability and noted limitations] (Include when relevant, e.g., one informant provided early milestone details while another was unavailable.)
• Interpreter: [offered and declined / used: in-person / used: video / used: phone]; [Interpreter ID if used] (Note language pair and any communication concerns.)
• Preferred language for healthcare discussion: [Language]
• Custody/consent context: [Relevant custody or guardianship information] (Include only if relevant to information-sharing or interpretation; omit if not applicable.)

Referral Context & Family Priorities

Referral source and question: [Who requested the evaluation and the primary question in plain language] (Include precipitating events or urgency if relevant.)

Caregiver chief concerns: [Primary concerns in caregiver's words] (Use brief verbatim quotes when they add clarity or preserve intent.)

• Family-stated priorities (1–3): [Priority 1]; [Priority 2]; [Priority 3] (Document "not specified" if family declines.)
• Functional goals: [What changes would improve daily life] (Link to routines, learning, relationships, or independence.)
• Supports tried and response: [What has helped / not helped and why] (Include barriers identified.)

History of Presenting Concern

[Narrative summary of onset and course] (Describe when the concern began; include developmental context; characterize time course as [stable / worsening / episodic / fluctuating].)

[Current presentation with concrete examples] (Summarize frequency, intensity, duration, triggers/antecedents, and setting variability across home/school/community. Attribute by source.)

[Functional impact] (Describe effects on learning, peer/family relationships, routines, safety, and independence.)

[Prior evaluations and diagnoses] (Include who diagnosed, approximate dates; distinguish records from caregiver report.)

[Interventions to date and response] (Therapies, medications, school interventions—what helped, what did not, reasons for discontinuation or barriers.)

[Safety concerns if clinically indicated] (Include only when relevant: aggression, self-injury, elopement, suicidality as age-appropriate. Document context and current safety plan if discussed. Omit this paragraph if no safety concerns are present.)

Developmental History

• Prenatal/perinatal history: [Pregnancy, delivery, gestational age, NICU or complications; early feeding/regulatory issues] (Summarize briefly for older youth if details are unavailable and not crucial to current evaluation.)
• Milestones (with ages):
  • Motor: [Gross and fine motor milestones]
  • Speech/Language: [First words, phrases, clarity/intelligibility]
  • Social communication: [Eye contact, joint attention, gestures, early play]
  • Adaptive: [Toileting, dressing, feeding, sleep]
  • Regression/early red flags: [Any loss of skills or early concerns] (Document "none reported" if applicable.)
• Current functioning by domain: (Include only domains pertinent to the referral question.)
  • Communication: [Expressive, receptive, pragmatics; AAC use; hearing concerns]
  • Social interaction and play: [Peer interactions, play preferences, reciprocity]
  • Learning/attention/executive function: [Learning profile, attention, organization, working memory]
  • Behavior regulation and emotional function: [Arousal regulation, mood, anxiety, coping, flexibility]
  • Sensory processing: [Hyper-/hypo-sensitivities, seeking/avoidance patterns] (Include only if relevant.)
  • Adaptive skills: [Current daily living skills, safety awareness, community navigation]

Medical History

• Major conditions/surgeries/hospitalizations: [Brief list relevant to interpretation]
• Neurologic history: [Seizures, head injury, neurologic diagnoses]
• Genetic conditions: [Known syndromes or genetic findings]
• Chronic illnesses: [Conditions pertinent to current evaluation]
• Current medications: [Name, dose, indication; adherence concerns if any]
• Vision and hearing: [Screening results or concerns with dates]
• Sleep/feeding/growth: [Relevant concerns] (Include only if pertinent to evaluation.)

Educational History

• Current placement: [Grade, setting: general education / inclusion / self-contained]; [Attendance concerns if any]
• Academic functioning: [Reading, writing, math, homework tolerance; notable strengths]
• Behavior at school: [Peer interactions, classroom behavior, disciplinary events]
• Supports and services: [IEP / 504 / none]; [Eligibility categories]; [Therapies, accommodations, paraprofessional support]
• Prior school-based testing: [Type, date, key conclusions] (Attribute to records vs. caregiver recollection.)
• Teacher input: [Summary of teacher reports] (Note discrepancies between home and school if present.)

Family & Psychosocial Context

• Household and caregiving: [Household composition; primary caregivers]
• Relevant family history: [Neurodevelopmental conditions, psychiatric history, speech/language disorders, intellectual disability, genetic conditions in biological relatives]
• Social determinants: [Housing stability, transportation, childcare, community resources] (Include if volunteered and relevant.)
• Trauma/adversity: [Brief, trauma-informed summary of what was reported and clinical relevance] (Do not force disclosure; include only what was volunteered.)
• Protective factors and strengths: [Family strengths, supports, coping resources, child interests/assets]

Records Reviewed

• External records: [Document type and date for each] (State "None available at time of interview" if applicable.)
• Collateral contacts: [Who contacted, date, key information obtained] (With documented permission.)

Interview Summary

[Synthesis of referral question and most relevant history] (Highlight key areas of agreement and discrepancy across informants or settings. Comment on reliability or limitations of history obtained.)

[Child and family strengths (1–3); preliminary impressions if any] (Label preliminary impressions explicitly as such and tie to reported information. This section bridges to the planned evaluation.)

Next Steps

• Additional information needed: [Specific records, rating scales, teacher input, releases requested]
• Assessments planned: [Testing sessions, observations, medical referrals]
• Immediate supports/resources provided: [Community resources, safety guidance, interim strategies] (Include only if applicable.)

Clinician Signature: [Electronic signature, name, credentials, date/time]