Psychological Assessment Report (Pediatric)

Patient Name: [Patient full name]

Date of Birth: [MM/DD/YYYY]

Medical Record Number: [MRN]

Caregiver(s): [Names and relationships of legal guardians and primary caregivers]

Referral Source: [Name, role, organization]

Evaluator(s): [Name, credentials, license number and state, specialty]

Date(s) of Evaluation: [Evaluation dates]

Report Date: [MM/DD/YYYY]

Consent and Confidentiality: [Documentation of informed consent from legal guardian, assent from child when developmentally appropriate, limits of confidentiality and mandatory reporting acknowledged, interpreter use if applicable with language and impact on testing]

Executive Summary

Referral Questions

• [Referral question 1]
• [Referral question 2]
• [Referral question 3]

(Include 1-5 questions driving the evaluation, including diagnostic differentials when relevant.)

Key Findings

Strengths: [Functional strengths across relevant domains]

Primary Needs: [Functional needs and impact on school, home, and peers]

Validity: [valid and interpretable / partially interpretable / not interpretable]. [If limited, specify affected domains and reasons]

Diagnostic Impressions

• [Diagnosis] ([DSM-5-TR or ICD-10 code]) [specifiers if applicable]
• [Additional diagnoses as applicable]
• [Diagnosis deferred or ruled out with brief rationale] (Only include if diagnosis was considered but not rendered.)

Priority Recommendations

(Provide 5-10 high-yield, actionable steps. Flag urgent safety items first if applicable.)

Medical/Behavioral Health:

• [Recommendation with responsible party, target outcome, and timeframe]
• [Referrals indicated with rationale]

School:

• [Supports and accommodations with rationale tied to functional impairments]
• [Indicate appropriateness for general education supports / 504 accommodations / IEP evaluation consideration] (Do not determine eligibility.)

Home:

• [Caregiver strategies and resources aligned to findings]

Reason for Referral and Presenting Concerns

[Who requested the evaluation and why now, including precipitating factors, prior diagnoses, and current interventions]

[Presenting concerns organized by relevant domains: academic/learning, attention/executive functioning, behavior/emotion regulation, social communication/peers, adaptive skills, sleep/somatic, safety concerns] (Include only domains with identified concerns.)

Sources of Information

• [Clinical interview participants and dates]
• [Records reviewed with dates: medical, school, prior evaluations]
• [Collateral informants: name/role, method, date]
• [Rating scales and questionnaires by informant]
• [Standardized tests administered with edition/version]
• [Behavioral observations in non-testing contexts] (Only include if applicable.)

Background History

(Focus on information that influences interpretation or recommendations. Omit sections not pertinent to current conclusions.)

Developmental History: [Pregnancy/birth, early milestones, temperament, sensory features]

Medical History: [Neurologic conditions, chronic illness, medications, vision/hearing status]

Family Psychiatric/Neurodevelopmental History: [Relevant conditions and relationships]

Educational History: [Current grade/placement, IEP/504 status, intervention history and response, academic trajectory]

Psychosocial Factors: [Cultural/linguistic context, stressors, trauma exposure if clinically relevant]

Strengths and Protective Factors: [Interests, supportive relationships, coping skills]

[Limitations of history and impact on conclusions] (Only include if critical history unavailable.)

Behavioral Observations and Mental Status

Testing Conditions: [Setting, individuals present, accommodations or assistive technology used]

Engagement and Behavior: [Rapport quality, attention and activity level, frustration tolerance, persistence, language comprehension and expression, social reciprocity and pragmatics, motor or sensory behaviors affecting performance]

Mental Status Observations: [Developmentally framed observations of mood, affect, orientation; safety concerns and actions taken if applicable]

Session Validity: [Overall validity of test performance; factors influencing results if any]

Assessment Procedures

(List measures with edition/version. Note departures from standardized administration with rationale.)

• Cognitive/Processing: [Measures]
• Academic Achievement: [Measures]
• Attention/Executive Functioning: [Measures]
• Language: [Measures]
• Memory/Learning: [Measures]
• Visual-Motor: [Measures]
• Behavioral/Emotional Rating Scales: [Measures by informant]
• Adaptive Functioning: [Measures and informant]
• Autism-Specific Tools: [Measures] (Only include if used.)
• Administration Notes: [Departures from standardization with rationale; assistive technology used] (Only include if applicable.)

Results

Score Interpretation Key: [Standard scores (M=100, SD=15), scaled scores (M=10, SD=3), T-scores (M=50, SD=10), percentiles, descriptive ranges used in this report]

(Organize by functional domain. For each: begin with plain-language summary and functional impact, then supporting scores. Document cross-informant consistency and embed interpretive cautions where applicable.)

Cognitive Profile

Summary and Functional Impact: [Plain-language description of cognitive strengths, weaknesses, and learning implications]

[Score patterns by index/subdomain with interpretive ranges; factors affecting interpretation; cross-source consistency: consistent / mixed / insufficient]

Academic Skills

Summary and Functional Impact: [Reading, writing, and math skills overview tied to classroom demands]

[Score patterns by subskill; instructional implications; cross-source consistency]

Attention and Executive Functioning

Summary and Functional Impact: [Attention, working memory, processing speed, inhibition, planning/organization; classroom and home implications]

[Test and rating scale findings; contextual explanations for discrepancies across settings or informants; cross-source consistency]

Language and Social Communication

Summary and Functional Impact: [Receptive/expressive language, pragmatic skills, conversational reciprocity]

[Score patterns and observations; cultural/linguistic considerations if applicable; cross-source consistency]

Memory and Learning

Summary and Functional Impact: [Immediate vs delayed recall, verbal vs visual memory, learning efficiency]

[Score profiles and qualitative observations; cross-source consistency]

Visual-Motor

Summary and Functional Impact: [Fine-motor integration, graphomotor output, visual-spatial construction; classroom implications]

[Scores and patterns; motor/sensory factors; cross-source consistency]

Emotional and Behavioral Functioning

Summary and Functional Impact: [Internalizing/externalizing symptoms, emotion regulation, behavior across settings]

[Rating scale results by informant with scores and ranges; interview and observation highlights; context-based explanations for informant discrepancies; cross-source consistency]

Adaptive Functioning

Summary and Functional Impact: [Communication, daily living, socialization, functional independence]

[Informant-based scores and ranges; limitations; cross-source consistency]

Diagnostic Formulation

Case Conceptualization: [Integrated narrative linking developmental trajectory, medical factors, learning profile, emotional/behavioral context, family/school systems, and cultural/linguistic considerations to presenting concerns and functional outcomes]

Differential Reasoning: [Evidence for and against key diagnostic alternatives considered] (Only include if diagnostic clarification was a referral question.)

Final Diagnoses: [Diagnosis name(s) with DSM-5-TR/ICD-10 codes and specifiers; if deferred, explain what would resolve uncertainty]

Risk and Safety Summary: [Current risk level, protective factors, actions taken] (Only include if risk was identified.)

Recommendations

(Tie each recommendation to functional findings. Use format: who should do what, targeting what outcome, within what timeframe.)

Medical/Behavioral Health

• [Therapy targets, modality, frequency, responsible provider]
• [Medication consultation considerations and monitoring plan] (Only include if within scope.)
• [Referrals with rationale: OT / speech-language / psychiatry / sleep / audiology / neurology / other]
• [Re-evaluation triggers and follow-up timeline]

School

• [Instructional interventions and supports linked to documented deficits]
• [Accommodations with rationales tied to functional impairments]
• [Behavior support strategies if applicable]
• [Appropriateness for general education supports / 504 plan / IEP evaluation consideration] (Do not determine eligibility.)
• [Progress monitoring plan and review interval]

Home/Caregiver

• [Daily routines, behavior strategies, environmental modifications]
• [Caregiver coaching or community resources]
• [Guidance for discussing results with the child in age-appropriate terms]
• [Contingency plans if symptoms worsen or interventions fail]

Care Coordination

• [Report recipients and format]
• [Suggested meeting agenda and timeline for school/medical teams]

Feedback Session

(Only include if feedback was provided.)

Date and Participants: [Names, roles, relationship to child]

Key Points Reviewed: [Main findings, diagnoses, and recommendations discussed]

Understanding and Agreement: [Caregiver/patient questions and level of agreement]

Immediate Decisions: [Referrals initiated, school contact, safety steps]

Appendices

(Optional. May include detailed score tables, rating scale summaries, documents reviewed, and abbreviations.)

Signature

Evaluator Signature: [Signature and date]

Credentials and License: [Degrees, license number and state]

Contact Information: [Clinic/department, address, phone, email]

Supervising Psychologist: [Name, credentials, license, signature and date] (Only include if supervisory co-signature required.)