How to write an autism assessment report in Australia

An autism assessment report in Australia should do four things: record how the assessment was done, state the diagnostic conclusion and the criteria behind it, describe the person's strengths and support needs in everyday terms, and give recommendations that someone else can act on. This guide shows one workable structure, based on the National Guideline for the Assessment and Diagnosis of Autism in Australia.

What does the national guideline say about the process?

The National Guideline was developed by Autism CRC. The first edition launched in 2018. A second edition followed in 2023, and its 66 Recommendations were approved by the National Health and Medical Research Council (NHMRC) on 8 December 2023. Each Recommendation comes with Good Practice Points that give clinical context.

The Recommendations are organised into five sections: guiding principles, foundations of assessment, making a referral, the Comprehensive Needs Assessment, and the Diagnostic Evaluation. The Introduction describes the pathway as a referral, an assessment of functioning, a medical evaluation and a diagnostic evaluation.

Your report should make clear which of these parts it covers. A report that mixes up "what this child needs" with "whether this child meets criteria" is hard for every reader to use.

Needs assessment or diagnostic evaluation: which one is your report?

Think of two questions.

• What is this person's functioning, and what supports would help? This is the needs side. The guideline's worked examples call it the assessment of functioning. Health professionals such as speech pathologists and occupational therapists, nurses and nurse practitioners can complete it, sometimes in partnership with colleagues in the same clinic.
• Does this person meet criteria for autism? This is the diagnostic side. The guideline supports assessment that may lead to a diagnosis under DSM-5-TR (2022) or ICD-11 (2019).

Some reports cover both. Others cover only one, with the rest done by another service. Say so in the first paragraph, and name the other reports you drew on.

Single clinician or team: how should the report show it?

The guideline now uses the term Lead Practitioner Diagnostic Evaluation. One practitioner leads, but draws on information and evidence from all relevant sources. If the lead practitioner cannot reach a confident outcome, they can invite colleagues with relevant expertise to form a Consensus Team Diagnostic Evaluation. The guideline's examples show a single paediatrician or psychologist completing most of the process, and also show teams that add a psychologist, occupational therapist or speech pathologist.

In the report, state:

• who led the evaluation and their profession and role
• who else contributed, and what each person did
• where the team agreed, and where they did not
• whether reassessment is suggested, and what would prompt it

In one of the guideline's examples, a team could not agree and recommended reassessment. Writing that down honestly is better than forcing a conclusion.

How do you report DSM-5-TR criteria?

Name the system you used (DSM-5-TR or ICD-11). Then go through each criterion and attach evidence to it. Do not just list tools and scores.

• Social communication and interaction. Describe what you saw and what carers and teachers reported, in specific, observable terms.
• Restricted and repetitive behaviours, interests or sensory differences. Describe them as they show up in the person's day, and note which ones help the person (for example, deep interests that build skills and joy).
• Onset, impact and other explanations. Say where information about early development came from, how the differences affect daily life, and which other explanations you considered.

Include the support level if you give one. The NDIS asks about the DSM-5 level (1 to 3), according to Amaze, and levels can be given separately for social communication and for restricted and repetitive behaviours. Explain what the level means for this person, in a sentence or two. A bare number tells a funder little.

How do you write strengths and support needs?

This is the part families, schools and funders use most. The guideline asks for neurodiversity-affirming practice and uses identity-first language ("autistic person"), while respecting individual preferences. Ask the family or the person how they describe themselves, and use that.

A practical approach:

• Start with strengths, in concrete terms. "Learns well from visual routines and has detailed knowledge of trains" is more useful than "has good visual skills".
• Describe support needs by situation: at home, in class, in the community, with peers.
• Say what helps. Note adjustments that already work.
• Avoid deficit framing such as "suffers from", "low-functioning" or "high-functioning". Describe what the person finds hard, and what changes in the environment would reduce that.

What should the recommendations say?

Recommendations should be specific, ordered, and aimed at a named reader.

• For the family: what to do first, in plain language, and where to find support.
• For the school: adjustments, communication supports and sensory considerations, tied to what you observed.
• For other clinicians: further assessment (for example speech, occupational therapy, cognitive or medical review) and why.
• For the person: where they are able to take part, how they would like to be supported.

Avoid generic lists. If a recommendation could sit in any child's report, rewrite it until it could only be this child's.

Writing so the NDIS can use it

Amaze, an autism organisation, reports that the NDIS looks for the diagnosis, how the condition limits taking part in activities without support, and whether support is likely to be needed for life. Reports from speech pathologists, occupational therapists, psychologists and paediatricians can all be part of the evidence. Check the current NDIS guidance for the exact evidence it asks for.

For the functional impact, describe what the person can and cannot do without support, how often support is needed, and in which settings. Keep that separate from the diagnostic reasoning so a planner can find it.

A section outline you can copy

Identifying details and reason for assessment

[Name, date of birth, date of report, referrer, who the report is for]

How the assessment was done

[Pathway: lead practitioner or team. Who contributed. Sessions, observations, information from family and school, tools used, and any limits]

Background

[Developmental, health, education and family information, in the family's words where possible]

Strengths and interests

[Specific strengths, interests and what helps]

Findings

[Communication, social interaction, repetitive behaviours and interests, sensory differences, learning, daily living. Evidence for each]

Diagnostic conclusion

[DSM-5-TR or ICD-11 criteria and evidence. Support level and what it means for this person. Other conditions considered]

Support needs in daily life

[By setting: home, school, community. How often and what kind of support]

Recommendations

[Ordered, specific, with a named reader for each]

Review and next steps

[When to reassess, what would change the picture]

Common mistakes

• Scores without meaning. A table of scores tells the reader nothing about the child's daily life.
• Criteria without evidence. "Meets criteria for social communication differences" with no example.
• Mixed pathways. Not saying who did what.
• Deficit-only language. Leaving out strengths.
• A report for one reader. A report too technical for the family, or too thin for the funder.
• Generic recommendations. Lists copied between reports.

In short

• Say whether your report covers needs, diagnosis or both, and who led it.
• Name the criteria system, and attach evidence to each criterion.
• Give strengths first, and support needs by setting.
• Write recommendations for named readers.
• Use the person's preferred language.
• Check current NDIS guidance for what the funder asks for.

Frequently asked questions

Who can diagnose autism in Australia? The guideline says diagnosis requires specific knowledge, skills and experience. It does not tie diagnosis to one profession. Its examples show paediatricians, psychiatrists and psychologists leading evaluations, with other professions contributing.

Do I need a team? Not always. A lead practitioner can complete the process. A consensus team is the step the guideline's examples use when the lead practitioner cannot reach a confident outcome.

Should I use identity-first language? The guideline uses identity-first language, reflecting the preferences of autistic and autism communities, and respects individual preferences in practice.

This guide is general information, not clinical or legal advice. Follow the full guideline and your professional body's standards.

Syntropic Health drafts reports like this from the whole case, in your clinic's template; the clinician reviews and signs. See clinical reports.

Sources

• autismcrc.com.au
• autismcrc.com.au
• autismcrc.com.au
• amaze.org.au