AUTISM ASSESSMENT REPORT
Confidential

Child: [Name, date of birth, age at assessment, pronouns]
Dates of assessment: [Each date, setting, and total hours]
Date of report: [Date]
Assessment team: [Each clinician's name, discipline, and credentials]
Referred by: [Referrer, and date of referral]
Parents or caregivers: [Names, relationship, language used, interpreter if any]

REASON FOR REFERRAL
Concerns: [What the family, school, or referrer noticed, in their own words]
Questions to answer: [Does the child meet criteria for autism; what support does the child need]
Screening before referral: [Tool, age, and result, such as the M-CHAT-R/F total and likelihood band; or none]

SOURCES OF INFORMATION
Parent interview: [Who took part, the date, and the interview used, such as the ADI-R or a developmental history interview]
School or childcare: [Teacher questionnaires, rating scales, or a visit, with dates]
Direct observation: [Structured observation, play or conversation in clinic, home or school visit]
Records reviewed: [Earlier screens, hearing and vision results, speech, school, or medical reports]

DEVELOPMENTAL HISTORY
Pregnancy and birth: [Gestation, complications, newborn course]
Early development: [Motor milestones, first words and phrases, pointing, response to name, pretend play]
Loss of skills: [Words or social skills lost, the age, and what happened since; or none]
Health: [Hearing, vision, sleep, eating, seizures, medications, genetic testing]
Family history: [Autism, language delay, ADHD, anxiety, intellectual disability, or other conditions in relatives]
Family and culture: [Household, languages spoken, childcare or school, what matters to the family]
Strengths and interests: [What the child enjoys, does well, and finds calming]

ASSESSMENT TOOLS AND RESULTS
Autism observation: [ADOS-2 module, classification, and comparison score; or the tool used]
Parent interview results: [ADI-R domains against the cutoffs; or a summary of the interview]
Rating scales: [Each scale, who completed it, the score, and its range]
Cognitive testing: [Test, composite or index scores, descriptive ranges; or not done, and why]
Language: [Test and scores, and the child's current level of spoken language]
Adaptive skills: [Test such as the Vineland-3, composite and domain scores]
Validity: [Engagement, breaks, language of testing, and anything that limits the results]

BEHAVIOR OBSERVED
Social communication: [Eye contact, gestures, shared attention, back-and-forth, response to name and to bids]
Play, behavior, and senses: [Play style, repetitive behavior, sensory responses, transitions]
Other settings: [What was seen at school, childcare, or home]

DSM-5-TR CRITERIA
A1 Social-emotional reciprocity: [Examples, now or by history, and the source]
A2 Nonverbal communication: [Examples and source]
A3 Relationships: [Examples and source]
B1 Repetitive movements, use of objects, or speech: [Examples, or not present]
B2 Sameness, routines, and rituals: [Examples, or not present]
B3 Intense or restricted interests: [Examples, or not present]
B4 Sensory reactivity: [Examples, or not present]
C Early onset: [Evidence the features were present in early childhood, and any masking]
D Impact: [How the features affect daily life at home, school, and with peers]
E Not better explained: [Why intellectual disability or global developmental delay does not account for the picture]

DIAGNOSIS
Diagnosis: [Autism spectrum disorder, with the code where you use codes; or criteria not met]
Support level, social communication: [Level 1, 2, or 3, and the reason]
Support level, restricted and repetitive behaviors: [Level 1, 2, or 3, and the reason]
Specifiers: [With or without intellectual impairment; with or without language impairment, and current language level; any associated genetic or medical condition, or neurodevelopmental, mental, or behavioral problem; catatonia if present]

DIFFERENTIAL AND CO-OCCURRING CONDITIONS
Considered and ruled out: [Each condition, such as hearing loss, language disorder, global delay, social anxiety, or ADHD, and why it fits less well]
Co-occurring conditions: [Anxiety, ADHD, sleep, eating, or medical conditions, and how each was assessed]

FEEDBACK
Feedback session: [Date, who attended, and how the diagnosis was explained]
Family's questions: [What the family asked, and the answers given]
Child's feedback: [What the child was told, in words that fit their age; or not appropriate yet]

RECOMMENDATIONS
Speech and language: [Service, focus, and frequency]
Occupational therapy: [Sensory, motor, eating, or daily living goals]
Developmental and behavioral supports: [Approach, setting, and parent coaching]
School or childcare: [Accommodations and support plan, shared with consent]
Family support: [Parent education, support groups, respite, funding or services programs]
Medical follow-up: [Genetic testing, hearing, sleep, or other referrals]
Review: [When to reassess, and what would prompt an earlier review]

Report shared with: [Each recipient, with consent for each]
Signed: [Each clinician's name, credentials, registration or license number, date]