The Center for Child Development Child’s Name:

Communication Therapy Initial Consultation Report Date:

COMMUNICATION THERAPY INITIAL CONSULTATION

Name: / File: / Umby#
Birthdate: / Report Date:
Age: / Diagnosis:
Session Dates:
Parent(s)
Legal Guardian:
Case Coordinator:
In attendance: / Parent/Caregiver / FSW / OT / PT / Psych / SCD / SLP
Other:
Setting: / Home / Centre / Preschool/Daycare
Information Sources: / File Review / Parent Report / Informal Observation / Formal Assessment

Caregiver’s Concerns:

Ø 
Communication Skills: / Appeared Typical / Difficulty
Observed / Not
Observed / Parent Concerns
Expressed / Assessment
Recommended
Receptive Language (understanding)
Expressive Language (verbal skills)
Speech Skills (clarity, fluency, voice quality)
Oral Motor Skills:
Pragmatics (social use of communication)
Gestures for Communication
Behaviour:
Attention
Play Skills

Comments:

Ø 

Clinical Impressions/Summary:

Ø 
Recommendations as discussed with family:
Parents to use teaching strategies as discussed and/or demonstrated.
Remain on waitlist for formal assessment and intervention as warranted.
Parents to be notified of upcoming therapy groups.
Enrollment in structured daycare/preschool/playgroups/community programs.
Child referred for hearing test.
Information provided to family on accessing private Speech and Language services: www.bcaslpa.ca
Child referred to: / Occupational Therapy (OT) / Physical Therapy (PT) / Family Services (FS)
Psychology (Psy) / Supported Child Development (SCD)
Infant Development Program (IDP)
Fraser Health Authority Audiology Clinic
Parent to talk with child’s physician regarding a referral to:
Pediatrician / Ear-Nose-Throat Specialist (ENT) / Fraser Health Assessment Network (FHAN)
Other:


CLINICAL INFORMATION

Home Language: / English / Comments:
Attends Preschool/Daycare: / No / Yes
Other Services Involved:
Pertinent Family/Social History:
Comments:
Hearing: / Tested within normal limits / Identified hearing loss / Not yet assessed
Comments:
Vision: / Tested within normal limits / Identified vision challenge
Not yet assessed / No parental concern
Comments:
Pertinent Medical History / Unremarkable
Comments:
Strengths: / Challenges:
Ø 
Registered Speech-Language Pathologist
604-584-1361 Ext.
Original: / Parent
c.c:

jj/company/Data/Shared/CT/Initial Consult DRAFT July-09