For clinicians conducting an interview (with a parent, caregiver, or teacher, for example) to obtain a developmental history before completing a cognitive assessment of a child. The template is designed to organise background information gathered in a pre-assessment interview in NovoNote and can be used in conjunction with the Child Cognitive Assessment Report template.
The structure includes the reason for referral, perinatal history, developmental milestones, medical history, family and social history, educational history, current functioning, previous assessments, current/previous interventions, strengths, and parent/carer concerns.
Identifying Information
Name:
Birthdate:
Parent(s)/Guardian(s):
Age:
Referred By:
Date of Referral:
Assessed By:
Date of Assessment:
Date of Report:
Reason for referral
Describe the reasons for seeking cognitive assessment including presenting concerns, onset and progression of issues, impact on daily functioning, and specific examples.
People present
List individuals present during the interview/assessment and their relationship to the child. State whether the child being assessed was present.
Background information
Provide information about the child’s current circumstances including school name, location, and current grade.
Perinatal history
Describe pregnancy history including maternal health, complications, substance use, and significant events. Detail birth history including delivery type, complications, and birth weight. Document neonatal period including feeding, sleeping, temperament, and any health concerns.
Developmental milestones
Motor development. Document gross motor milestones (head control, rolling, sitting, walking) and fine motor skills (grasping, drawing, writing), noting any delays or concerns.
Language and communication development. Detail early language development including first words, sentences, receptive and expressive abilities. Document non-verbal communication including eye contact, gestures, and understanding of social cues.
Cognitive development. Describe early cognitive skills including problem-solving, memory, conceptual understanding, and academic readiness.
Social-emotional development. Detail social development including attachment, play with others, sharing, and friendship formation. Describe emotional development including emotional regulation, frustration tolerance, and response to stress.
Adaptive skills development. Document self-care skills including feeding, dressing, and toileting. Detail daily living skills including household tasks, safety awareness, and age-appropriate independence.
Play and interests. Describe play development including types of play, preferred activities, and any unusual or restricted interests.
Medical history
Document general health history including chronic conditions, hospitalisations, and significant medical events. Detail any sensory issues, allergies, gastrointestinal problems, sleep patterns, and existing diagnoses.
Family and social history
Describe family composition, cultural background, socioeconomic factors, caregiving history, family mental health history, trauma history, and support systems.
Educational history
Detail school history, academic performance, special services or accommodations, classroom behaviour, and parent-teacher relationships.
Current functioning
Document daily routine, academic functioning, social skills, behavioural and emotional functioning, self-care abilities, and family management strategies.
Previous assessments
Detail any prior evaluations including timing, administrator, and key findings.
Current and previous interventions
Describe therapeutic interventions and medications including timing, frequency, providers, and effectiveness.
Strengths, interests and hobbies
Document child’s strengths, unique skills, advanced abilities, and positive personality traits.
Parent/carer concerns and goals
Detail current concerns and priorities from parent perspective and specific goals for the child’s development.
Clinician observations, notes and impressions
Provide clinician’s impressions of parent-child interactions and hypotheses about factors contributing to presentation.
Developmental profile summary
Provide concise overview of developmental strengths and challenges, patterns, and significant contributing factors.
Assessments administered
For each cognitive assessment tool used, provide a short paragraph to describe each assessment. Repeat this process for each cognitive assessment conducted. Print the following subheadings, which the clinician can use as a template for recording assessment results:
Assessment results
Full Scale Score:
Verbal Comprehension:
Visual Spatial:
Working Memory:
Fluid Reasoning:
Processing Speed:
Behavioural observations
Space for clinician to document the child’s behaviour during assessment.
Summary and clinical impressions
Space for clinician to document overall clinical conclusions.
Recommendations
Space for clinician to document suggested interventions and support strategies.
Identifying information
Name: Oliver James Brown
Birthdate: 18/03/2018
Parent(s)/Guardian(s): Sarah and Michael Brown
Age: 7 years, 2 months
Referred By: Dr. Rebecca Wilson, Paediatrician
Date of Referral: 02/04/2025
Assessed By: Dr. Emma Taylor, Educational and Developmental Psychologist
Date of Assessment: 12/05/2025
Date of Report: 25/05/2025
Reason for referral
Oliver was referred for cognitive assessment by Dr. Rebecca Wilson (Paediatrician) due to ongoing academic difficulties and concerns about attention and concentration. According to his parents, he has struggled with reading despite school interventions. They report that Oliver frequently loses focus during homework and has difficulty following multi-step instructions in class. His difficulties became pronounced in Year 1 with increased literacy demands. Oliver expresses frustration when reading, stating “I’m just dumb at reading,” and has recently developed a reluctance to attend school, complaining of “tummy aches” on school mornings.
People present
Background information
Oliver currently attends Year 2 at Wattle Grove Primary School in Melbourne, where he has been enrolled since Year 1.
Perinatal history
Mrs. Brown reported an uncomplicated pregnancy and birth at 39 weeks gestation. Oliver’s birth weight was 3.4 kg with normal Apgar scores. The neonatal period was generally smooth, though he was described as a “fussy feeder” with irregular sleep patterns until 9 months of age. He was noted to be sensitive to loud noises and routine changes from early infancy.
Developmental milestones
Motor development: Oliver’s parents reported that he achieved gross motor milestones within normal timeframes but was cautious with new physical activities. Fine motor skills have presented ongoing challenges, with current handwriting described as “laborious and messy with frequent letter reversals.” His physical education teacher has noted difficulties with ball skills and coordination activities.
Language and communication development: According to the parents, Oliver’s language development followed typical patterns with good receptive skills. His expressive language is generally age-appropriate, though he sometimes struggles to organise his thoughts when excited. His non-verbal communication has developed appropriately with normal eye contact and gesture use.
Cognitive development: Oliver’s early cognitive development was reported as age-appropriate. He demonstrates good verbal memory and learns well through auditory and hands-on approaches. His parents indicated that he struggles more with visual information and written instructions.
Social-emotional development: The Browns described Oliver’s social development as typical, with several consistent friendships. He experiences emotions intensely and sometimes struggles with regulation, particularly during challenging academic tasks. He responds to stress by withdrawing rather than acting out.
Adaptive skills development: Oliver achieved self-care milestones at typical ages but continues to need assistance with fine motor tasks such as buttoning and tying shoelaces. He requires prompting to complete routine tasks and benefits from additional supervision in new environments due to his distractibility.
Play and interests: Oliver’s play has developed typically and currently centres around science topics and construction activities. He becomes frustrated with tasks requiring sustained attention but shows no unusual or repetitive play patterns.
Medical history
The parents reported good general health with no chronic conditions. Hearing and vision screenings have been normal. Oliver experienced several ear infections in early childhood that resolved without complications. His sleep patterns are generally regular with occasional difficulty falling asleep when anxious about school.
Family and social history
Oliver lives with his parents and younger sister in Melbourne. Family relationships are described as close and stable. There is a family history of reading difficulties (maternal uncle with dyslexia) and attention problems (father with adult ADHD). No history of trauma or significant adversity was reported.
Educational history
School reports indicate that Oliver performs below year level in literacy but shows strengths in mathematics and science. He receives small-group literacy intervention and has an Individual Education Plan with classroom accommodations. His behaviour at school is generally compliant, though he frequently “daydreams” during independent work and requires redirection.
Current functioning
Oliver requires significant prompting to complete daily routines. His reading is approximately one year behind peers, though his mathematics performance is at grade level. He maintains age-appropriate social relationships but struggles with organisation and task completion. His parents use consistent routines, task breakdown, and movement breaks to support his functioning.
Previous assessments
A speech and language screening at age 4 indicated age-appropriate language skills. No comprehensive cognitive or academic assessments have been previously conducted.
Current and previous interventions
Oliver receives school-based literacy intervention three times weekly. His parents have implemented a home reading program with variable success. No medications have been prescribed.
Strengths, interests and hobbies
Oliver demonstrates strong verbal reasoning skills and scientific curiosity. He shows creativity in storytelling and constructs complex LEGO models when engaged. His parents and teacher describe him as caring, empathetic, and inquisitive with an advanced vocabulary for his age.
Parent/carer concerns and goals
The Browns are primarily concerned about Oliver’s literacy development and its impact on his self-confidence. They worry about his increasing anxiety about school and attention difficulties. Their goals include improving his reading skills, enhancing his attention, rebuilding his academic confidence, and helping him develop effective coping strategies.
Clinician observations, notes and impressions
During the interview, both parents demonstrated good insight into Oliver’s development. The information they provided suggests a pattern of verbal and conceptual strengths alongside challenges in fine motor skills, attention, and literacy. The family history of reading difficulties and ADHD suggests possible neurodevelopmental factors contributing to his presentation.
Developmental profile summary
Oliver presents with age-appropriate development in most domains but demonstrates significant challenges in literacy acquisition, fine motor skills, and sustained attention for non-preferred tasks. His verbal and social-emotional abilities represent areas of strength, while his difficulties with reading and attention are impacting his academic progress and emotional wellbeing. The combination of his presentation and family history warrants comprehensive assessment to clarify his learning profile and develop appropriate interventions.
Assessments administered
Assessment results
Full Scale Score:
Verbal Comprehension:
Visual Spatial:
Working Memory:
Fluid Reasoning:
Processing Speed:
Behavioural observations
Summary and clinical impressions
Recommendations
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