Client Information
Name
Date of Birth
Assessment Date
Caregiver(s)
Assessor
Referral Reason
Assessment Methods
Background Information
Medical History
Developmental History
Educational History
Previous Services
Strengths
Areas of Concern / Challenges
Assessment Results
Communication
Social Skills
Adaptive Skills
Behavioral Concerns
Cognitive Skills
Motor Skills
Summary and Recommendations
Proposed Goals
Signatures
Assessor Signature
Date
Caregiver Signature
Date