Child Details

This information is only used to generate your printable document. Nothing is saved or sent to any server.

Child's Initials or First Name

Age

1. Social & Communication

Select any observed traits and provide a specific example of what this looks like in daily life.

Struggles to make/maintain eye contact Takes jokes or sarcasm literally Talks 'at' people rather than 'with' them Struggles to read facial expressions 'Masks' at school but melts down at home Prefers to play alone / struggles with peer groups

Specific Examples (Crucial for doctors):

2. Routines, Interests & Sensory

Highly distressed by sudden plan changes Intense hyper-fixation on specific subjects Covers ears for loud noises (hand dryers, sirens) Cannot tolerate clothing tags or specific seams Uses repetitive movements to calm down (flapping, rocking) Constantly seeks deep pressure or crashes into things

Specific Examples:

3. Focus & Impulsivity

Seems driven by a motor / physically cannot sit still Loses focus instantly unless highly interested Highly impulsive / lacks danger awareness Forgets instructions halfway through a task Interrupts or blurts out answers in school Struggles heavily with time management/transitions

Specific Examples:

4. Impact on Daily Functioning

Referral panels look for "significant impairment". How are these traits affecting the family's ability to function?

School Impact (e.g., School refusal, detentions, falling behind, exhaustion after school):

Home & Wellbeing Impact (e.g., Severe sleep issues, restrictive eating, self-harm, impact on siblings):

Neurodevelopmental Observation Summary

Confidential Parent/Carer Report

Child: Age: Date:

1. Social Interaction & Communication

2. Routines, Sensory & Repetitive Behaviors

3. Attention, Focus & Impulsivity

4. Functional Impact Summary

Impact on Education & School Life:

Impact on Home Life, Health & Wellbeing:

This document was generated by the parent/carer to assist with clinical triage and assessment pathways.