Treatment Plan: $ Page XXX $
Sir Alexander Ewing-Ithaca College Speech and Hearing Clinic
Ithaca College, Ithaca, New York 14850
Treatment Plan
Name: (omit fill final version) Date of Plan:
(Initial Submission Date)
Address: (omit fill final version) Date of Birth: (omit till final version)
Phone: (omit fill final version) Age:
Parents: (omit fill final version) Diagnosis:
Supervisor: Skott Freedman, Ph.D., ICD 9 Code: (Non Billable)
CCC-SLP
Clinician: CPT Code:
Statement of the Problem
This is the main reason your client has been receiving/will receive therapy. Indicate the nature and severity of the problem, describing specific behaviors. If the therapy is accent reduction in nature, simply state the client wishes to reduce their ____-accented English and be sure not to classify it as a diagnosis or disorder. In this case, the term “language enhancement” should be used if non-articulation goals are also being targeted (e.g., plurals).
Summary of Therapy History
Indicate when and where services were received, and for how long. Include a brief summary of targeted goals and progress made. If applicable, summarize IEP goals related to SLP.
Current Level of Performance (Standardized or baseline testing results)
This is your baseline from the first 2-3 sessions. Try using tables to make information easily accessible to the reader. Make sure you measure what you need for developing your goals.
Therapy Goals and Rationales
For each goal, include 1) specific behavior, 2) type and amount of cues, and 3) criteria.
Long-Term Goal 1:
Rationale
(provide author, year, and evidence)
Short-Term Objectives:
1.
2.
3.
4.
Long-Term Goal 2:
Rationale
(provide author, year, and evidence)
Short-Term Objectives:
1.
2.
3.
4.
Long-Term Goal 3:
Rationale
(provide author, year, and evidence)
Short-Term Objectives:
1.
2.
3.
4.
Frequency and Intensity of Therapy
$ $
Student Clinician Clinical Supervisor
$ Date
Signature of Patient or Guardian
(Parent or guardian if client is under 18)