Autism Spectrum Disorder Evaluation
General Information
Client Name
Date of Birth
Evaluation Date
Evaluator Name/Title
Presenting Concerns
Developmental History
Pregnancy & Birth History
Early Developmental Milestones
Medical & Family History
Medical History
Family History (including ASD, mental health, etc.)
Educational History
School/Daycare Information
Academic Performance
Assessment Methods
Interviews conducted with:
Behavioral Observations
Standardized Tests/Measures Used
Core Symptom Domains
Social Communication & Interaction
Repetitive Behaviors and Restricted Interests
Other Relevant Behaviors (sensory, motor, etc.)
Summary & Impressions
Diagnosis (DSM-5 Criteria)
Recommendations