The pediatric neuropsychiatric exam may at first seem daunting and unwieldy, given its broad scope and integrative aims. The wide range of patients, concerns, diagnoses, and treatments can be overwhelming; but like many other complex evaluations in neurology and psychiatry, a deliberate, systematic-yet-flexible approach to the assessment can serve to anchor and orient clinicians and support patients. Much of the approach has to do with observation and “being in the moment” with a patient and family. Oliver Sacks wrote, “There is only one cardinal rule: One must always listen to the patient (Sacks O, Migraine. University of California Press, Berkeley, 1970),” and this adage, to always listen and maintain an open mind, holds especially true in pediatric neuropsychiatry. While rating scales and paper and pencil tests may be handy, they do not always represent the best method of information gathering for those with complex disorders of emotion, behavior, cognition, and consciousness. An organized clinical rubric, albeit one that is flexible and scalable and leaves room for creativity, makes the most sense for a variety of situations. Given that, our aim in this chapter is to offer a template that can be tailored to many types of clinical needs. This method may not fit all clinical scenarios, but it can serve as a starting place and a structure for how to approach the exam.