Observer History Form

1

About You & the Person Being Assessed

Your name *

Your relationship to the client *

If other, please describe your relationship

How long have you known this person? *

How often do you see or interact with them now?

Client's full name *

Client's date of birth *

2

Early Development

Pregnancy & Birth

Were there any significant complications during pregnancy or birth? e.g. premature birth, birth complications, significant maternal illness or stress, substance exposure

No Yes Not sure

If yes, please describe briefly

3

Attention, Activity & Impulse Control — Childhood

Thinking about their behaviour during childhood (roughly ages 5–12), please rate how often each of the following applied.

Any other comments about their attention, activity level, or impulse control in childhood?

4

Social Communication & Interaction

The following questions relate to social and communication patterns across their life. Please answer based on what you have observed over time.

Non-Verbal Communication

How would you describe their use of eye contact with others?

Did their facial expressions or body language ever seem out of step with what they were saying or feeling? e.g. appearing flat or neutral when they were actually happy, or laughing at an unexpected moment

No / rarely Sometimes Often Not sure

5

Interests, Routines & Repetitive Behaviour

Interests

Did they have very intense or all-consuming interests or hobbies — topics they knew an unusual amount about or were preoccupied with?

No / not noticeably Yes, as a child Yes, as an adult Yes, throughout life

If yes, please describe the interests and how they engaged with them

Routines & Rigidity

Did they insist on routines or become very distressed when plans changed?

No / rarely Sometimes Often Not sure

How did they typically respond to unexpected changes?

Did they have repetitive movements or habits? e.g. hand-flapping, rocking, spinning, finger movements, vocal sounds, or repeating certain phrases or movements when excited or distressed

No / not noticeably Yes, as a child Yes, as an adult Yes, throughout life

If yes, please describe briefly

6

Sensory Sensitivities

Some people are significantly more sensitive (or less sensitive) to sensory input than most people. Please indicate whether any of the following apply or have applied to them.

Please tick any that apply or have applied

Very sensitive to sounds — bothered by noises others did not notice Very sensitive to touch — bothered by clothing textures, tags, or light touch Very sensitive to smell or taste — very selective eating or distressed by certain smells Very sensitive to light — bothered by bright lights Unusually high pain tolerance — seemed not to notice injury or pain Sought out strong sensory input — liked pressure, loud sounds, intense movement No significant sensory sensitivities noticed

Any comments about sensory sensitivities?

7

School & Learning

How would you describe their experience at school overall?

Were any of the following ever raised by teachers or school staff? Please tick all that apply.

Attention or concentration difficulties Behaviour difficulties Social difficulties or peer relationship problems Learning difficulties or falling behind Anxiety or emotional difficulties Possible ADHD or ASD Giftedness or advanced ability Nothing significant was raised

Did they ever receive extra support at school, or were they assessed by a school psychologist or specialist?

No Yes Not sure

If yes, please describe briefly

8

Emotions & Emotional Regulation

How would you describe their emotional regulation — their ability to manage strong feelings?

Have you observed any of the following? Please tick all that apply.

Intense emotional reactions that seemed out of proportion Difficulty calming down once upset Very low frustration tolerance Mood changes that seemed sudden or unpredictable Persistent worry or anxiety Periods of low mood or depression Seemed to feel emotions less than others, or had difficulty identifying their own feelings None of the above

Any comments about their emotional life?

9

How They Present Now

This section focuses on how they currently present — as an adult. Please base your answers on what you have observed recently.

Current Attention & Organisation

How would you rate their attention and organisation as an adult?

Please describe any specific attention or organisation difficulties you observe in them now

Current Social Functioning

How would you describe their social functioning now as an adult?

Have you noticed them masking or making deliberate efforts to fit in socially? e.g. rehearsing conversations, copying others' behaviour, appearing fine in public but exhausted afterwards

No / not that I've noticed Possibly Yes Not sure

Describe any current social difficulties or patterns you have observed

Overall Current Impression

In which areas of their life do you see the greatest difficulty at the moment? Tick all that apply.

Work or study Managing daily tasks and responsibilities Relationships Mental health or emotional wellbeing Financial management Physical health and self-care Social participation No significant areas of difficulty currently

10

Family History & Additional Information

To your knowledge, is there a family history of any of the following? Please tick all that apply.

ADHD (diagnosed or suspected) Autism / ASD (diagnosed or suspected) Learning difficulties (e.g. dyslexia) Anxiety or anxiety disorders Depression Bipolar disorder Other mental health conditions Not aware of any family history

Is there anything else you think would be important for the psychologist to know? This is your opportunity to share anything that has not been covered — including things that concern you, significant life events, or other observations.

How confident are you in the accuracy of the information you have provided?

About You & the Person Being Assessed

Early Development

Pregnancy & Birth

Early Milestones

Early Social & Communication

Attention, Activity & Impulse Control — Childhood

Social Communication & Interaction

Friendships & Relationships

Communication Style

Non-Verbal Communication

Interests, Routines & Repetitive Behaviour

Interests

Routines & Rigidity

Sensory Sensitivities

School & Learning

Emotions & Emotional Regulation

How They Present Now

Current Attention & Organisation

Current Social Functioning

Overall Current Impression

Family History & Additional Information

Thank you — your report has been submitted.