Early Intervention Evaluation
Child's Information:
Name:
Date of Birth:
Date of Evaluation:
Evaluator's Information:
Name: [Your Name]
Contact Information: [Your Email]
Introduction:
This evaluation aims to assess the developmental progress of [Child's Name] in various domains. The information gathered will be used to determine if early intervention services are necessary. Confidentiality Statement: All information provided in this evaluation will be kept confidential and used solely for assessment and intervention purposes.
Developmental Domains:
Physical Development:
Assessment Tool: ____________________
Instructions: _________________________
Scoring Criteria: ______________________
Observation Notes:___________________
Cognitive Development:
Assessment Tool: ______________________
Instructions: _________________________
Scoring Criteria: ______________________
Observation Notes:___________________
Communication Development:
Assessment Tool: ______________________
Instructions: _________________________
Scoring Criteria: ______________________
Observation Notes:
Social-Emotional Development:
Assessment Tool: ______________________
Instructions: _________________________
Scoring Criteria: ______________________
Observation Notes:____________________
Adaptive Development:
Assessment Tool: ______________________
Instructions: _________________________
Scoring Criteria: ______________________
Observation Notes:___________________
Parent/Guardian Input:
Please provide information about your child's development, concerns, and family history.
Developmental Milestones: _______________________
Medical History: _______________________________
Previous Evaluations/Interventions: _______________
Recommendations: Based on the evaluation findings, the following recommendations are suggested:
Referral for further evaluation: __________________
Early intervention services: ____________________
Strategies for supporting development at home: ______
Signatures: I acknowledge that I have reviewed the evaluation findings and recommendations.
[YOUR NAME]
[DATE SIGNED]
[PARENT/GUARDIAN]
[DATE SIGNED]
Evaluation Templates @ Template.net
