Sample Child Outline

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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




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