The focus should be upon the student being evaluated and the area of concern. Do not spend too much time writing about the obtained scores instead write about what these scores mean.
In stating the reason for referral, you should cue the reader as to the purpose of the report. Tell him what case you are building. You do not want him to get to the end of your report, then have to read it again to see if your conclusions were supported. Let him be forming this judgment while he reads.
Have a plan! Know where you are going; what conclusions you are building toward. If you start writing with the idea that you will figure out some conclusions when you get to the end of the report, you will need to do extensive rewriting to make the report flow smoothly and to remove the unnecessary details.
If the student is too psychotic, disorganized, or uncooperative to be evaluated, then be specific about why you were unable to complete the evaluation and what efforts you took to try to motivate cooperation. Be sure your reader understands that you put forth appropriate effort.
Avoid using jargon or terms for which there is little consensus as to their meaning. State what you observe rather than just saying “hyperactive” or “poor pragmatics.”
When referring to yourself in a report there is no clear consensus whether you should use personal pronouns or refer to yourself as “the examiner.” Many professionals feel that referring to yourself in the third person makes the report sound more objective and formal. Others feel that it makes the report sound awkward and stilted.