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An ADHD evaluation report is the written product of a diagnostic assessment for attention-deficit/hyperactivity disorder. It integrates the referral question, history, observations, and multi-informant rating scales into a DSM-5-TR criteria mapping, a differential, a diagnosis, and recommendations. Psychologists, psychiatrists, pediatricians, and primary care prescribers write them for children and adults. Most run 3 to 10 pages and are shared with families, schools, and prescribers.
Psychologists and neuropsychologists; psychiatrists, pediatricians, and primary care prescribers documenting their own diagnostic assessments
The referrer and the prescriber, the client and family, schools on request, payers and auditors; in Australia, the state unit behind a stimulant authority
1,000 to 3,500 words (3 to 10 pages) · 2 to 5 hours of interviews, scoring, and writing (clinical team estimate)
Interpretive assessment report (compare: psychological, psychoeducational, and neuropsychological reports)
When attention, hyperactivity, or executive-function complaints need a diagnostic answer: first diagnosis, medication decisions, school or workplace supports, or a second opinion
No law mandates the format; AAP, CADDRA, and AADPA guidelines set the convention, and stimulant-authority rules give the content legal teeth
An ADHD evaluation report is the written product of a diagnostic assessment for attention-deficit/hyperactivity disorder. It integrates a clinical and developmental interview, standardized rating scales from more than one informant, and any cognitive or achievement testing into an explicit mapping of findings onto DSM-5-TR (or ICD) criteria, then states a diagnosis, the differential that was considered, and recommendations. Clinicians and payers also call it an ADHD assessment report, an ADHD diagnostic assessment, or a comprehensive ADHD evaluation; when a full test battery drives it, it becomes a psychological evaluation report billed under the testing codes. It is a document family rather than a single instrument: the rating-scale tradition runs from the Conners scales of the 1960s to today's Conners 4 and CAARS 2, and the guideline scaffolding comes from the American Academy of Pediatrics, which first published ADHD evaluation recommendations in 2000 and last revised them in 2019, Canada's CADDRA practice guidelines (4.1 Edition, January 2020), and Australia's NHMRC-approved AADPA guideline, developed from systematic reviews new and updated from NICE 2018.
Here is the fact that organizes everything else on this page: no statute, regulator, or payer in the US, Canada, or Australia mandates the report's format, and yet this document has more legal teeth than almost any other note a mental health clinician writes, because it is what stands behind a controlled-substance prescription. Australian state law makes that explicit: NSW defines ADHD for stimulant-authority purposes as a diagnosis meeting DSM-5 or ICD-11 criteria, and prescribing runs through a class authority that names who may hold it. In the US the diagnosis itself needs no physician signature, but prescribing does, and federal telemedicine flexibilities for prescribing stimulants without a prior in-person exam currently run only through December 31, 2026. The report is also narrower than its neighbors: an interview-based first diagnosis at the start of routine care is a psychiatric diagnostic evaluation, a school-eligibility evaluation is a psychoeducational report, and this page covers the focused diagnostic document that answers one question: does this person meet criteria for ADHD, and what should happen next?
Psychologists and neuropsychologists write them in private practice and clinics; psychiatrists, pediatricians, and primary care prescribers write leaner versions documenting their own diagnostic assessments, which is where most childhood ADHD is actually diagnosed. The numbers explain the volume: about 1 in 9 US children has ever received an ADHD diagnosis, and an estimated 15.5 million US adults had a current diagnosis in 2023, about half of them diagnosed in adulthood. The report is the right tool when attention, hyperactivity, or executive-function complaints need a diagnostic answer: a first diagnosis in a child whose teacher and parent see different things, an adult seeking evaluation after years of workplace difficulty, a medication decision that needs a documented basis, or a second opinion after an online diagnosis. For children the evidence spine is multi-informant rating data like the Conners 4 with a BRIEF-2 for executive function; for adults it is the CAARS 2 with collateral input where available; cognitive context from a WISC-V or WAIS-5 joins only when the referral question asks for it. When the question is school eligibility rather than diagnosis, the psychoeducational report takes over; when the developmental question is broader than attention in a young child, a developmental assessment comes first; and when the referral spans injury, decline, or a full battery, the neuropsychological or psychological evaluation report is the wrapper. The audience is wider than the chart: the referrer and the prescriber read it to act, parents and adult clients read it to understand, schools read it to plan supports, and in Australia a state pharmaceutical-services unit may read it before a stimulant authority issues.
No authority mandates a single format. The sections below are the consensus skeleton of the AAP, CADDRA, and AADPA guideline tradition and the elements payers and stimulant-authority reviewers expect to find, each with the pitfall that most often undermines it.
Identifying information and referral question. Client, date of birth, evaluation dates, evaluator and credentials, referrer, and the question in one sentence: who is asking, and what decision does the answer feed? Pitfall: a report with no referral question cannot show medical necessity, and payers read testing done purely for school accommodations as an educational service, not a covered one.
Sources of information and consent. List every source: interviews and dates, informants, rating scales with versions, tests, records reviewed, and who consented. Note the modality if any part ran by telehealth. Pitfall: an unlisted source cannot support a criterion later; if a teacher scale never came back, say so and describe the workaround.
History. Developmental, medical, psychiatric, family, and school or work history, including sleep, substance use, prior evaluations, and treatment. For adults, evidence of childhood symptoms: report cards, a parent's account, an old evaluation. Pitfall: onset undocumented. Symptoms must be traceable to before age 12, and "client recalls being distractible" carries less weight than a named source.
Behavioral observations. What you saw across sessions: attention, activity, effort, rapport, and whether results looked valid. One line on interpretability protects every score that follows. Pitfall: observations that contradict the conclusion with no comment; a child who sustained attention for 90 minutes of one-on-one testing needs a sentence explaining why that does not rule out ADHD in a classroom of 25.
Rating-scale results, by informant. Each instrument with version, informant, setting, and scores presented the way the manual scales them, then the pattern: where informants agree, where they diverge, and what the divergence means. Pitfall: one informant, one setting. The AAP guideline expects "documentation of symptoms and impairment in more than 1 major setting," and a parent-only profile leaves the second setting unevidenced.
Cognitive and achievement context, when tested. If a WISC-V, WAIS-5, or achievement measure was given, report it here as context: no cognitive profile diagnoses ADHD, but the results answer rule-out questions and shape recommendations. Pitfall: implying IQ or achievement testing was required for the diagnosis; no guideline in the US, Canada, or Australia requires it, so justify the battery you gave.
DSM-5-TR criteria mapping and differential diagnosis. The engine of the report: criterion by criterion, which symptoms are endorsed, by whom, in which settings, since when, with what impairment, and what else could explain them: sleep, anxiety, depression, learning problems, substance use, medical causes. Pitfall: scores treated as the verdict. A rating scale is evidence toward criteria; the mapping is the diagnosis, and a report that skips from T-scores to diagnosis will not survive a records review.
Diagnosis and formulation. The conclusion with presentation and severity, the ICD-10-CM code payers will see (F90.0, F90.1, F90.2, F90.9), conditions ruled out, and a short formulation connecting history, data, and impairment. State it even when the answer is no ADHD; a documented negative protects the client and the next evaluator. Pitfall: hedged conclusions ("consistent with possible ADHD") that neither support treatment nor close the question.
Recommendations, feedback, and signature. Ranked, specific, and matched to the findings: behavioral treatment, school or workplace strategies, medication discussion with the prescriber where indicated, and follow-up. Document the feedback session, who received the report, time for any time-based testing codes, and sign with credentials and date. Pitfall: a psychologist's report that reads as a prescription; diagnosis is yours, prescribing is the physician's, and in Australia the state authority's.
ADHD EVALUATION REPORT Client: ______________________ DOB: ____________ Age: ______ Evaluation date(s): ______________ Report date: ____________ Evaluator / credentials: ______________________________________ Referred by: ____________________ Modality: [ ] In person [ ] Telehealth REFERRAL QUESTION _____________________________________________________________ SOURCES OF INFORMATION AND CONSENT Interviews / informants: ____________________________________ Rating scales (version, informant, setting): ________________ Tests administered: ______________ Records reviewed: ________ Consent obtained from: ______________________________________ HISTORY (developmental, medical, psychiatric, family, school/work) _____________________________________________________________ Evidence of symptoms before age 12: _________________________ BEHAVIORAL OBSERVATIONS / VALIDITY STATEMENT _____________________________________________________________ RATING-SCALE RESULTS (by informant and setting) _____________________________________________________________ COGNITIVE / ACHIEVEMENT CONTEXT (if tested) _____________________________________________________________ DSM-5-TR CRITERIA MAPPING AND DIFFERENTIAL Inattention: ____ of 9 endorsed. Sources: ___________________ Hyperactivity-impulsivity: ____ of 9. Sources: ______________ Settings with impairment: ______________ Onset: ____________ Alternatives considered / ruled out: ________________________ DIAGNOSIS AND FORMULATION Diagnosis (ICD-10-CM code): _________________________________ Formulation: ________________________________________________ RECOMMENDATIONS, FEEDBACK, AND FOLLOW-UP 1. ___________________________________________________________ 2. ___________________________________________________________ Feedback session / report shared with: ______________________ Testing time (if time-based codes billed): __________________ Signature / credentials: ______________ Date: ______________
Free to use and share, no signup. The PDF includes a one-page cheat sheet with section-by-section pitfalls and a pre-sign checklist; the DOCX is the blank template, ready to adapt.
Scenario: a licensed psychologist evaluates a 9-year-old referred by her pediatrician after two years of classroom attention concerns. A full report runs 3 to 10 pages; this version is condensed but structurally complete. Use it as an ADHD evaluation report sample you can adapt for children or adults. All details are fictional.
ADHD EVALUATION REPORT (CONFIDENTIAL)
Client: M.R., age 9, grade 4 · DOB: 03/2017
Evaluation dates: 07/07/2026 and 07/14/2026 · Report date: 07/21/2026
Evaluator: L. Chen, PhD, Licensed Psychologist · Referred by: A. Okafor, MD (pediatrician)
Referral question. Dr. Okafor asks whether M.R. meets criteria for ADHD and what supports are indicated, ahead of a medication discussion the family has requested.
Sources of information and consent. Two in-person sessions with M.R.; parent interview with mother; developmental and medical history questionnaire; Conners 4 (parent and teacher forms); BRIEF-2 (parent form); WISC-V (selected indexes); review of report cards, grades 1 to 4, and the pediatrician's referral note. Teacher forms completed by the grade 3 teacher in June, before the school break. Written consent from mother; assent from M.R.
History. Unremarkable pregnancy and delivery; milestones on time. Teachers have noted incomplete work and difficulty sustaining attention since grade 1; report cards repeat "loses focus" and "needs reminders" across three years. Homework requires constant supervision at home. Hearing and vision screened normal 04/2026. Sleep is adequate on the family's account (about 10 hours, regular schedule). No medications, no prior mental health treatment, no significant medical history. Family history includes attention problems in father, never formally evaluated. No recent stressors or changes at home.
Behavioral observations. M.R. was friendly and engaged. She required repetition of instructions on longer tasks, left her seat twice per session, and lost track of multi-step directions, but persisted with encouragement. Effort was adequate across both sessions; results below are considered interpretable. Sustained one-on-one attention here does not contradict classroom reports; demands differ sharply between settings.
Rating-scale results. Conners 4 parent form: Inattention and Executive Function scales Very Elevated (T = 78 and 74); Hyperactivity T = 62. Conners 4 teacher form: Inattention Elevated to Very Elevated (T = 71); Hyperactivity within the average range. BRIEF-2 parent form: clinically meaningful elevations on Working Memory and Plan/Organize indexes. The two informants agree on inattention across home and classroom and agree that hyperactivity is not the primary picture.
Cognitive context. WISC-V estimated overall ability in the average range (FSIQ 102); Working Memory Index 88, a relative weakness consistent with the rating-scale profile. Academic skills per records and curriculum measures are broadly at grade level, with written output the weakest area. No learning disorder is identified on this screening; fuller achievement testing was not indicated by the referral question.
DSM-5-TR criteria mapping and differential. Inattention: 7 of 9 symptoms endorsed by parent and 6 of 9 by teacher, present in both home and classroom. Hyperactivity-impulsivity: 3 of 9, below threshold. Onset: documented from grade 1 (age 6). Impairment: incomplete classwork, homework supervision burden, rising frustration around school. Alternatives considered: anxiety (subclinical on interview and scales), learning disorder (not supported by screening), sleep disruption (not supported by history), medical causes (screened by pediatrician). None better explains the pattern.
Diagnosis and formulation. ADHD, predominantly inattentive presentation, moderate (F90.0). A capable child whose working-memory weakness and inattention undermine performance as academic demands grow; strengths include verbal reasoning, warm family support, and willing engagement.
Recommendations. (1) Share this report with the school, with parental consent, to support classroom strategies and consideration of a formal support plan. (2) Parent behavior-management training; resources provided. (3) Return to Dr. Okafor for the medication discussion; this report documents the diagnostic basis. (4) Re-evaluate response in 3 to 6 months; repeat teacher ratings once new-year placement settles.
Feedback and signature. Findings reviewed with mother 07/21/2026; plain-language summary provided. Report released to Dr. Okafor with consent. L. Chen, PhD, Licensed Psychologist, signed 07/21/2026.
This sample is fictional and for educational purposes. It does not describe a real patient.
Writing these after every session? BastionGPT drafts complete notes from bullets, dictation, or a transcript.
Generate a note from bulletsWrite the report knowing who will read it. It sits in the designated record set, so the client, or a parent for most minor clients, holds a right of access under 45 CFR 164.524, and a finalized electronic report is releasable by default through the portal, often before the feedback session. Release to a school is a disclosure the parent authorizes, and it changes the audience: a report headed for a student support meeting should carry its conclusions in plain language and keep raw data out of the narrative. The rules for releasing test data versus test materials are the same as for any testing report; the psychological evaluation report page covers them in detail. Retention runs on the whole-chart clock, which is state or provincial law rather than a single national rule: commonly 5 to 10 years by state in the US, with the APA's record-keeping guideline suggesting 7 years, or 3 years past majority for minors, as the default; at least 10 years after last contact, or 10 years past the 18th birthday, under Ontario's college standard; and 7 years for adults or until age 25 for minors in Australian state regimes. An ADHD report written for a child will be requested again a decade later, for a college accommodation or an adult re-evaluation, so write it to be read cold.
The compliance pressure sits in two places, and neither is the format. First, payment. In the US the interview-based diagnostic evaluation bills 90791 or 90792, brief rating scales ride under 96127 where payers allow, and the timed testing codes (96130, 96131, 96136, 96137) apply only when standardized instruments are administered and interpreted; contractor policy is blunt that self-scored inventories are not testing, that testing "administered for educational or vocational purposes" without a medical-management purpose is excluded, and that time must be documented for time-based codes. In Australia there is no dedicated ADHD-assessment item; psychiatrist assessments run under attendance items like 291, where the explanatory note makes the document itself the deliverable: "The detailed report is a fundamental component of this item" (MBS note AN.0.30). Second, prescribing. The report is what a prescriber, and in Australia a state pharmaceutical unit, relies on before a stimulant is authorized: NSW requires a diagnosis meeting DSM-5 or ICD-11 criteria under its class authority, Queensland's December 2025 reform lets specialist GPs initiate psychostimulants for adults on the strength of a documented assessment, and US telemedicine prescribing without a prior in-person exam runs on DEA flexibilities that expire December 31, 2026 unless extended or replaced. Those rules change month to month, so date-stamp any prescribing statement in your report. The format is a convention; the content, and what it authorizes, is the requirement.
ADHD evaluations are under enforcement scrutiny that most document types never see. In June 2024, federal agents arrested the founder and the clinical president of the telehealth company Done, whose platform, per the government's charges, arranged prescriptions of over 40 million pills of Adderall and other stimulants for more than $100 million in revenue on a monthly-subscription model with an auto-refill function; a jury convicted both in November 2025 of conspiracy to distribute controlled substances and health care fraud conspiracy. The lesson for legitimate practice is not that telehealth evaluation is suspect; it is that the evaluation document is the control point regulators read, and a thin one now carries real risk. The BastionGPT Clinical Advisory Board sees the same errors most often in ADHD evaluation report reviews:
BastionGPT is specifically trained, tuned, and clinically tested on ADHD evaluation reports.
See how clinicians use it day to day on the AI therapy notes page.
Many BastionGPT users report saving more than 90 minutes per day on documentation.
HIPAA-compliant with a signed BAA on every plan. Your data is never used to train models. BastionGPT drafts, you review and sign.
No. No statute, regulator, or payer in the US, Canada, or Australia prescribes the report's title, section order, or length; the familiar structure is professional convention set by the AAP guideline in the US, CADDRA's guidelines in Canada, and the NHMRC-approved AADPA guideline in Australia. The binding rules attach to content and consequences instead: payer documentation requirements, retention and access law, and the stimulant-authority rules that decide what the report must establish before prescribing. Most reports run 3 to 10 pages and take 2 to 5 hours of interviewing, scoring, and writing, a clinical team estimate.
It depends on the jurisdiction, and the answers are moving. In the US a psychologist's diagnosis is valid, but prescribing needs an authorized prescriber, and DEA flexibilities allowing telemedicine stimulant prescribing without a prior in-person exam run only through December 31, 2026 unless extended or replaced. In Australia the report feeds a state authority: NSW defines ADHD as a diagnosis meeting DSM-5 or ICD-11 criteria under its class authority for psychiatrists, paediatricians, and neurologists, and Queensland lets specialist GPs initiate psychostimulants for adults from 1 December 2025, with other states phasing in GP roles on their own timetables. In Canada, physicians prescribe; a psychologist's report informs but cannot authorize. Date-stamp any prescribing statement you make.
No guideline in the US, Canada, or Australia requires one for a routine clinical diagnosis. The strongest endorsement any of these tools has is as an add-on: NICE's 2024 guidance names QbTest an option for ages 6 to 17 and says "It should only be used with standard clinical assessment by a healthcare professional," with adult use still research-only, and the systematic review behind that decision concluded it "should not be used as stand-alone screening or diagnostic tool." The AAP guideline likewise reports that neuropsychological testing "has not been found to improve diagnostic accuracy in most cases." Cognitive testing joins when the referral question needs it, and high-stakes accommodation or licensing contexts effectively expect more, including validity data; a routine diagnosis needs a thorough clinical assessment, not a specific instrument.
No law requires a teacher scale for anyone. For children it is strong guideline convention: the AAP expects DSM-based rating scales from parents and school sources, because the criteria demand evidence from more than one setting, and for adolescents it suggests reaching at least two teachers or other adults who see the student work. For adults there is no teacher-scale analogue; observer input from a partner, parent, or colleague on an instrument like the CAARS 2 observer form is best practice rather than a requirement, and childhood evidence (report cards, a parent's account) does the onset work instead. When an informant never returns a form, document the attempt and what you relied on in its place.
By what was actually done. An interview-based diagnostic evaluation is 90791 (or 90792 with medical services); brief rating scales ride under 96127 where payers allow, with per-day unit caps; and the timed testing codes (96130, 96131, 96136, 96137) apply only when standardized instruments are administered and interpreted, with the time documented. Contractor policy adds the traps: self-scored inventories are not testing, and testing "administered for educational or vocational purposes" without a medical-management purpose is excluded, which is how school-accommodation referrals become denials. When a full battery drives the evaluation, the work product is a psychological evaluation report and its billing rules apply. In Australia there is no dedicated ADHD-assessment item; psychiatrist assessments run under attendance items such as 291, where the explanatory notes make the written report to the referrer the core deliverable.
No rule anywhere requires quoting criteria text or using the TR edition specifically. What reviewers look for is the mapping: which symptoms, endorsed by whom, in which settings, since when, with what impairment, and what else was ruled out. NSW makes the edition point explicit by accepting a diagnosis meeting DSM-5 or ICD-11 criteria for stimulant authority, and US claims use ICD-10-CM codes (F90.0, F90.1, F90.2, F90.9) regardless of which manual framed the assessment. Reproducing pages of criteria text adds copyright risk and no clinical value; the evidence under each criterion is what makes the report defensible.
Same family, different questions. The ADHD evaluation report answers a focused diagnostic question and may rest on interview plus rating scales alone. A psychological evaluation report is the battery-driven wrapper billed under the testing codes; a psychoeducational report answers a school-eligibility question under education law, which is also why insurers treat school-purpose testing as not medically necessary; a psychiatric diagnostic evaluation is the interview-based start of routine care; and a young child with broader developmental questions starts with a developmental assessment. Autism evaluations use different instruments and criteria entirely. Pick the document that matches the referral question, and say so in the first paragraph.
Retention is state or provincial law on the whole-chart clock: commonly 5 to 10 years by state in the US, with the APA guideline suggesting 7 years, or 3 years past majority for minors; at least 10 years after last contact, or 10 years past the client's 18th birthday, under Ontario's college standard; and 7 years for adults or until age 25 for minors under Australian state rules. Access is broader than most evaluators expect: the report sits in the designated record set under 45 CFR 164.524, parents generally hold a minor's right, portals release finalized reports by default, and schools see it whenever a parent authorizes release. A child's report resurfaces years later for college accommodations or an adult re-evaluation, so write every section to be read cold by a stranger.
Yes. Bring the evaluation however it exists: interview notes, dictation, score summaries, a records chronology. BastionGPT drafts the report in your structure, from referral question through criteria mapping, differential, and recommendations, tabulates multi-informant scores by setting, produces the plain-language version for parents or the client, and checks the draft for the failure points this page lists: an unanswered referral question, a criterion with no named source, missing onset evidence, or an unjustified battery. BastionGPT is HIPAA-compliant with a signed BAA, and data is never used to train models.
Educational content, not legal or billing advice. Sample notes are fictional. Follow your organization's policies and your board, payer, and jurisdiction requirements.