Suggested Format for Integrative Reports

INTEGRATIVE REPORT
Name of Agency
Agency Address
Agency Contact Phone Numbers

NAME OF ASSESSMENT TOOL USED

(Child’s) Name: Referral Date:

(Child’s) Date of Birth: Parent Interview Date:

(Child’s) Age: Child Evaluation Date:

(Child’s) Corrected age: (when appropriate) Parent Conference Date:

INITIAL REFERRAL

(Who made it and for what reason) EVALUATION PROCESS

(A brief paragraph of what was done and by whom

·  Who did the evaluation and who was present

·  What process was followed? Include all tools and forms completed. Include other documentation drawn from.

·  Where the evaluation took place. Describe the environmental effects on the evaluation, if pertinent.)

RELEVANT DEVELOPMENTAL HISTORY/HEALTH STATUS

(The purpose here is to offer a complete picture of the child’s development integrating all domains. The writer should review the standard forms and medical records, as well as encompass the information gathered in the interview with the family and direct observations of the child/parents in daily activities and at play, in their natural, most comfortable environments.

This should be a summary and include the following

·  Relevant family/environmental information, including family composition and relationships, parent concerns, availability of support system

·  Health information including pertinent prenatal, birth and peri- natal information; significant health events; current health status including results of lead levels, vision and hearing screening

·  Developmental information/history including developmental milestones, any special problems or developmental concerns

·  Other professionals involved; family resources

·  Parent/CG’s idea/attitudes about their child/parenting and their own description of their child.

·  Description of the home environment and other environments in which the child spends significant time.

Throughout, use objectively descriptive wording. Include quotes and anecdotes the family shares to support qualitative statements.

For children with complex family histories such as family instability, violence, drug use or other problems, discretion must be used. Usually it is possible to note problems, but to omit great detail. For example, “That was a stressful time for the family” may be sufficient. If it feels essential to include sensitive information, employ transcriptions and factual narrative.)

DISCOVERIES WHILE OBSERVING (INSERT NAMES OF PARENTS AND CHILD)

(The purpose here is to understand the child’s development in terms of interactions and relationships within the context of his care-giving environment. The writer aims to integrate all areas of development. It is based on direct observations of the child’s behavior and parent-child interactions during natural caretaking or play activities.

Using objectively descriptive words and quotes, give a picture of the qualities of the interaction from perspectives of: the parents/CG to their child, the child to the parents/CG, the child to playthings/environment. Qualitative statements should be supported by factual narrative, quotes and anecdotes.

· Can include aspects of communication, body language, goodness of fit, interactive movement or games, engagement, interests, play/learning style, attachment style and other features that are notable

· Highlight unique capacities and strengths that parents/CG demonstrate in taking care of their child and the unique strengths and capacities the child demonstrates in interactions with parents/CG and their environment.)

DEVELOPMENTAL FINDINGS

(As an overall statement, begin with a reminder of the child’s chronological age and a note indicating that the eight domains of the Provence Profile were assessed.

Looking for a developmental competency level of

Describe the child as a whole on the day of the evaluation. Include the child’s physical appearance, the child’s adaptation to the evaluation, the relationship to the examiner, and other factors that seem relevant (tiredness, illness, etc). Qualitative details such as cooperation, attention, interest in tasks can also be included when documented concretely.

Follow this with documentation of competency achieved in each specific area of the assessment. Include descriptive information based on the actual strengths and interests of the child and family.

For Example:

Gross Motor Amy is competent at the 21-24 month level.

Amy moves easily from a squatting position to standing and back to squat, on her own, as she plays. Mom reports that she walks up the stairs holding the railing, but not yet alternating feet. She can kick a ball and jump off the floor with both feet. She runs well, enjoying chasing her brother as he rides his tricycle in their back yard. When her dad, Jeff, said “See how I can lift my foot? You do it ...” Amy giggled and lifted first her left foot, then with prompting from dad, stood on her right foot for a few seconds too. She put her arms out to balance.

SUMMARY

(This is a summary paragraph briefly synthesizing the report. This includes a statement of the child’s developmental picture, including current status and findings. All issues raised in the referral or during the assessment should be addressed in the summary, and only issues that have been addressed in the evaluation should appear here. This is the wrap-up, and should give the reader the sense that all the important issues were addressed. )

RECOMMENDATIONS and PLAN

·  What are the action steps resulting from the evaluation? Who, what, when, where, how – be specific.

·  This is a nice place to include at least one positive comment acknowledging what parents/CG are already doing that is strengthening their family and supporting their child’s development. Encourage them to continue and build upon their recognized strengths.

·  Relate recommendations/plans to expressed family concerns, needs and priorities.

SIGNATURES and TITLES OF EVALUATORS

CC’s