Intellectual Disability Services Assessment Sheet
Personal Information
Name
Date of Birth
Gender
Address
Phone Number
Primary Contact
Assessment Details
Date of Assessment
Assessor Name
Diagnosis
Relevant Medical History
Communication
Communication Abilities
Preferred Communication Method
Daily Living Skills
Skill
Level of Independence
Support Needed
Personal Hygiene
Feeding
Dressing
Mobility
Toileting
Behavioural Assessment
Behaviour Observed
Behaviour Supports Needed
Social & Community Participation
Interests/Hobbies
Community Activities Involved
Support Required for Participation
Recommendations
Client/Guardian Signature
Name
Date