PSYCHOLOGICAL ASSESSMENT REPORT
Confidential

Client: [Full name, date of birth, age at testing]
Dates of assessment: [Testing dates and total hours of direct contact]
Date of report: [Date]
Assessed by: [Psychologist name, credentials, registration or license number]
Supervised by: [Name and credentials, or not applicable]
Referral source: [Physician, school, self, lawyer, employer, or other]

REFERRAL QUESTION
Questions to answer: [Each question the assessment must answer, as the referrer framed it]
Why now: [The event or concern that prompted the referral]
Intended use: [Diagnosis, treatment planning, accommodations, or another decision the report will inform]

CONSENT AND REPORT RECIPIENTS
Informed consent: [Purpose, procedures, fees, and limits of confidentiality explained; date consent was signed]
Report recipients: [Who receives the full report and who receives a summary letter, with written consent for each]
Feedback: [Date of the feedback session, and who attended]

SOURCES OF INFORMATION
Interviews: [Client, and each informant with consent and their relationship]
Records reviewed: [Report cards, earlier assessments, medical or work records]
Tests administered: [Each test by full name and edition, with the date given]

BACKGROUND
Presenting concerns: [The problems as the client describes them, with onset and course]
Developmental history: [Pregnancy, birth, milestones, early concerns, or not known]
Educational history: [Schools, grades, learning support, earlier testing, highest level completed]
Medical history: [Conditions, medications, vision, hearing, sleep, head injury]
Psychiatric history: [Earlier diagnoses, therapy, medication, hospital stays]
Family history: [Learning, attention, mood, and substance use problems in relatives]
Social and occupational: [Household, relationships, work or study, culture and first language]
Substance use: [Alcohol, cannabis, other drugs, and caffeine or medication on testing days]

BEHAVIORAL OBSERVATIONS AND VALIDITY
Presentation: [Appearance, rapport, speech, mood, and affect during testing]
Test-taking behavior: [Effort, attention, pace, frustration, and strategies you saw]
Testing conditions: [Language of testing, glasses or hearing aids, breaks, and any departure from standard procedure]
Validity: [Performance and symptom validity results, and whether the scores fairly estimate current functioning]

RESULTS
Score ranges used: [The descriptive scheme applied to every test, such as standard scores of 90 to 109 called average]
Intellectual functioning: [Test, index scores, percentile ranks, and descriptive ranges]
Academic achievement: [Test, composites and subtests, standard scores, percentile ranks, and ranges]
Attention and executive functioning: [Self and observer rating scales as T-scores, and any performance tasks]
Memory and processing: [Tests and scores, or not assessed]
Emotional and personality functioning: [Inventories and screens: validity scales, then clinical elevations]

INTEGRATED INTERPRETATION
Findings by question: [What scores, history, and observations show together, grouped under each referral question]
Strengths: [Abilities and resources the client can build on]
Where sources disagree: [Any conflict between tests, informants, or history, and how you weighed it]

DIAGNOSTIC CONCLUSIONS
Diagnoses: [Each diagnosis with specifiers and severity, and the code where you use codes]
Basis: [How each diagnostic requirement is met, summarized in your own words]
Considered and ruled out: [Other conditions, and why they explain the findings less well]
Answers to the referral questions: [A direct yes, no, or partly to each question]

RECOMMENDATIONS
Treatment: [Therapy, medication review, or other care, and who provides it]
Accommodations: [Each accommodation at school or work, tied to the finding that supports it]
Strategies and supports: [Skills training, technology, coaching, or community services]
Follow-up: [Reassessment if needed, and when]

SUMMARY FOR THE CLIENT
Plain-language summary: [What we looked at, what we found, what it means for you, and what happens next]

Signed: [Psychologist name, credentials, registration or license number, date]