This NovoNote template produces a report detailing the findings of a comprehensive ADHD and/or autism assessment. The template is the perfect accompaniment for clinicians who have used NovoNote’s clinical interview templates:
Or for those who have conducted an assessment using the MIGDAS-2 or DIVA-5 clinical interviews on NovoNote.
By combining information from these clinical interviews and data from psychometric assessments from NovoPsych, this template can synthesise that information into a comprehensive diagnostic report for GPs, medical specialists, and other key stakeholders such as schools and government departments.
Name of Recipient
Address of Recipient
Re: Client First and Last name
DOB:
Address:
Dear Recipient Name,
The following report refers to a comprehensive ADHD / autism assessment of Client’s Name. Summarise assessment purpose and context:
Information Sources
Personal and Developmental History
Medical Status and Medical History
Mental Health History
Medication History
Drug and Alcohol Use History
Other Addiction History
Legal and Forensic History
Current Presentation / Functional Assessment
Mental Status Examination
Strengths, Coping Skills, Recreational Interests, and Hobbies
Psychometric Assessment
Formulation/Impression
Diagnosis
Risk
Recommendations
Summary
If you have any questions about the contents of this report, please feel free to contact me.
Yours sincerely,
Clinician Name
Dr. Rebecca Thompson
123 Medical Centre Drive
Melbourne, VIC 3000
Re: Mary Blogs
DOB: 15/06/1995
Address: 456 Residential Street, Melbourne, VIC 3001
Dear Dr. Thompson,
The following report refers to a comprehensive ADHD assessment of Mary Blogs.
This assessment was conducted following Mary’s referral from her general practitioner to evaluate persistent attention and concentration difficulties that have been significantly impacting her occupational functioning and daily life management. Mary is a 28-year-old woman of Australian-European background who required no specific modifications during the assessment process.
Information Sources
Personal and Developmental History
Mary was born following an uncomplicated full-term pregnancy and delivery. Early developmental milestones, including walking and speech, were achieved within normal timeframes, though she recalls being described by teachers as “daydreamy” and “easily distracted” from early primary school. Family history is significant for paternal ADHD diagnosed in adulthood and maternal generalised anxiety disorder. Mary’s academic trajectory showed a pattern of underachievement relative to her intellectual capacity, with particular difficulties in organisational skills and task completion becoming more pronounced during secondary education. Despite these challenges, she completed a Bachelor of Arts degree but required extensions for most assignments and reported feeling chronically overwhelmed by academic demands. Mary currently works part-time as an administrative assistant and lives independently in a shared apartment.
Medical Status and Medical History
Mary reports no significant medical conditions and takes no regular medications. She experienced one episode of concussion at age 16 following a sporting accident, with no ongoing neurological sequelae reported. Mary has not undergone any previous neuropsychological or cognitive assessments.
Mental Health History
Mary has a history of episodic depression first occurring during university years, for which she received counselling through university services but no formal diagnosis or ongoing treatment. She reports these episodes were typically triggered by academic stress and feelings of being overwhelmed by competing demands. Mary accessed brief private psychology services in 2022 for anxiety management, attending approximately six sessions focused on stress reduction techniques. She has never required psychiatric hospitalisation or crisis intervention services.
Drug and Alcohol Use History
Mary reports minimal alcohol consumption, typically limiting intake to 1-2 standard drinks per week in social settings. She has never used tobacco products and denies any history of illicit drug use. Mary consumes moderate amounts of caffeine daily, approximately 2-3 cups of coffee, which she reports helps with concentration and alertness, particularly during work hours.
Current Presentation / Functional Assessment
Mary presents with a longstanding pattern of inattention, distractibility, and executive dysfunction that significantly impairs her occupational and daily functioning. She describes persistent difficulty with task initiation, frequently feeling overwhelmed when faced with multiple competing demands, and an inability to sustain attention during meetings or detailed administrative tasks. Mary reports losing important documents, frequently forgetting appointments despite using reminder systems, and experiencing chronic lateness due to poor time estimation skills. Her sleep pattern is irregular, with difficulty settling due to racing thoughts and mental hyperactivity in the evening hours. Mary has developed compensatory strategies including regular physical exercise and structured daily routines, which provide some symptom relief. Current functional impairment is most evident in occupational settings, where she requires frequent supervision and struggles to meet deadlines independently.
Mental Status Examination
Mary presented as appropriately groomed and casually dressed with good personal hygiene and appropriate eye contact throughout the interview. She appeared alert and fully oriented, displaying cooperative engagement and appropriate rapport with the examiner. Her speech was clear, coherent, and goal-directed with normal prosody and volume, though she occasionally lost her train of thought mid-sentence when discussing complex topics. Mary demonstrated intact cognitive functioning with no evidence of thought disorder, perceptual disturbances, or significant mood disturbance during the assessment.
Strengths, Coping Skills, Recreational Interests, and Hobbies
Mary demonstrates considerable creative abilities, particularly in visual arts including painting and photography, where she reports experiencing a state of focused attention that contrasts markedly with her difficulties in other domains. She has developed effective stress management strategies through regular jogging and hiking, which she identifies as essential for mood regulation and mental clarity. Mary shows strong interpersonal skills and maintains supportive friendships, demonstrating good emotional intelligence and empathy in her relationships. Her insight into her difficulties and motivation to seek appropriate intervention represent significant strengths that bode well for treatment engagement.
Psychometric Assessment
Adult ADHD Self-Report Scale (ASRS-v1.1) completed on 15 March 2024
Mary endorsed 5 out of 6 symptoms in Part A, indicating a high likelihood of ADHD. Her responses revealed significant difficulties with attention to detail, sustaining attention on tasks, organisation of tasks and activities, and avoiding tasks requiring sustained mental effort, consistent with predominantly inattentive presentation.
Wender Utah Rating Scale (WURS-25) completed on 15 March 2024
Mary achieved a total score of 72, substantially exceeding the clinical cut-off of 46 for retrospective childhood ADHD symptoms. Her endorsements included persistent patterns of inattention, daydreaming, difficulty completing tasks, and organisational problems during childhood, supporting the developmental persistence of ADHD symptoms from childhood through to adulthood.
Conners’ Adult ADHD Rating Scale (CAARS) Self-Report Long Version completed on 15 March 2024
Significantly elevated scores were obtained on the Inattention/Memory Problems subscale (T-score 78) and DSM-5 Inattentive Symptoms subscale (T-score 75), while Hyperactivity/Restlessness remained within normal limits (T-score 52). The ADHD Index yielded a T-score of 71, indicating clinically significant ADHD symptomatology.
Formulation/Impression
Mary presents with a neurodevelopmental profile consistent with ADHD predominantly inattentive presentation, characterised by persistent attention regulation difficulties, executive dysfunction, and organisational challenges that have been present since childhood and significantly impair current functioning. Predisposing factors include genetic vulnerability evidenced by paternal ADHD, suggesting inherited neurobiological differences in attention regulation and executive control systems. The predominantly inattentive presentation may have contributed to later recognition, as her symptoms were less disruptive in classroom settings compared to hyperactive-impulsive presentations. Precipitating factors include increasing organisational and multitasking demands in her current work environment that exceed her executive functioning capacity, leading to chronic stress and secondary mood difficulties. Perpetuating factors include the absence of appropriate accommodations and ADHD-specific interventions, resulting in ongoing functional impairment and the development of negative self-concepts around competence and reliability. Protective factors include Mary’s strong insight, treatment motivation, established healthy lifestyle practices, and supportive social relationships that provide both practical and emotional support.
Diagnosis
F90.0 Attention-Deficit/Hyperactivity Disorder, Predominantly inattentive presentation (ICD-11: 6A05.1 Attention deficit hyperactivity disorder, predominantly inattentive presentation)
Mary meets DSM-5-TR criteria for ADHD predominantly inattentive presentation based on the presence of six inattentive symptoms that have persisted for at least six months, are inconsistent with developmental level, and cause clinically significant impairment in occupational functioning. Symptoms were present before age 12 as evidenced by collateral history and retrospective symptom assessment, occur across multiple settings, and are not better explained by another mental disorder. The convergent evidence from clinical interview, collateral information, and standardised psychometric assessment strongly supports this diagnostic conclusion.
Risk
Mary presents with low risk for self-harm, suicidal ideation, or harm to others. She explicitly denied any current or historical suicidal thoughts during assessment and demonstrates numerous protective factors including strong social support, effective coping strategies, and good treatment engagement. Her current stress levels, while elevated, do not appear to pose immediate safety concerns.
Recommendations
Summary
Mary’s comprehensive assessment provides strong evidence for ADHD predominantly inattentive presentation, with significant functional impairment across occupational and daily living domains. With appropriate multimodal intervention including medication, psychological support, and workplace accommodations, Mary demonstrates excellent potential for improved functioning and quality of life outcomes.
If you have any questions about the contents of this report, please feel free to contact me.
Yours sincerely,
Sarah Smith
Clinical Psychologist
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