Last name, first name
DOB
SPEECH AND LANGUAGE EVALUATION
Authorization Period: to
Patient: / PCP:DOB: / Facility:
Parents: / Address:
Phone:
Chronological Age: / Phone:
Adjusted Age (if appropriate): / Fax:
Date of Evaluation: / CC:
Therapist: / Medicaid #:
BACKGROUND INFORMATION/ MEDICAL HISTORY
Medical Diagnosis:
Prenatal/Birth History:
Medical History:
Developmental Milestones:
Previous Therapy History:
Current Additional Services:
Hearing Status: Vision Status:
Current Educational Placement:
Current Equipment Use:
Current Medications:
Allergies:
Referral Source:
Accompanied by:
Parental/Caregiver Concerns:
Additional Comments:
ASSESSMENT INFORMATION
Language Tests Administered in:Choose an item.
Modifications to testing procedures included:
Evaluation Methods Implemented to Assess Communication Skills:
Formal MeasuresInformal Measures
Informal Measures Included:
Caregiver Report Clinical Observation
Behavioral Observations:
LANGUAGE DEVELOPMENT
Within normal limits for age
Areas assessed include auditory comprehension (understanding of language) and oral expression (use of language), pragmatic, social and play skills. Results of formal assessment are as follows:
Test Name: Choose an item.
Raw Score / Standard Score / Percentile / Age- Equivalent / Severity RatingAuditory Comp.
Expressive Comm.
Total Language
Comments:
Test Name: Choose an item.
Raw Score / Standard Score / Percentile / Age- Equivalent / Severity RatingAuditory Comp.
Expressive Comm.
Total Language
Comments:
Auditory Comprehension (Receptive Language):
Strengths:
Areas for Development:
Oral Expression (Expressive Language):
Strengths:
Areas for Development:
Additional Assessment Information:
ORAL MOTOR FUNCTION/STRUCTURE
A cursory oral peripheral examination was unremarkable. All oral structures and musculature appear intact for speech and feeding.
Unable to assess due to: Fatigue Compliance Other:
A cursory oral peripheral examination revealed:
Skills Affected: Articulation/ Speech Feeding/Swallowing Other:
ARTICULATION
Refers to way sounds are produced and/or sequenced together.
Within normal limits for age
Unable to formally assess due to:
Informal Measures Used:
Scores: Choose an item.
Raw Score / Standard Score / Percentile / Age Equivalent / Severity RatingConversational Intelligibility (connected speech):
Phonemic Inventory (if appropriate):
Phonological Processes (if appropriate):
Articulation Errors/Distortions:
Initial Position:
Medial Position:
Final Position:
Blends:
Additional Comments:
VOICE
Refers to quality and/or frequency of ones voice.
No concerns noted at this time.
Formal Measure:Choose an item.
Unable to assess due to:
Indicate and describe areas of concern:
Vocal Quality: breathy shrill hoarse harsh weak glottal fry
no voice other:
Pitch: too high too low monotone other:
Additional Comments:
FLUENCY
Refers to the flow and/or rate of speech.
No concerns noted at this time.
Unable to assess due to:
Formal Measure: Choose an item.
Indicate and describe areas of concern:
Rate of Speech: too fast too slow other:
Description of dysfluencies:
Secondary Behaviors:
Percentage of speech affected:
Severity Rating:
Additional Comments:
FEEDING / SWALLOWING
Means of Intake:
Bottle Fed Open Cup Breast Fed Sipper Cup Straw Tube Fed
Utensils (spoon and/or fork) Self- feeds
Current Diet:
Puree Food (stage 1) Junior Food (stage 2/3) Semi -Solids Table Foods
Comments:
Feeding /Swallowing skills are:
within functional limits for age.
of concern. Feeding/Swallowing Evaluation recommended.
ASSESSMENT
SPEECH/ LANGUAGE/FEEDING DIAGNOSIS
(Listed in order of primary concerns)
Choose an item/delete if not using
Choose an item/delete if not using
Choose an item/delete if not using.
THERAPEUTIC PROGNOSIS
Excellent Good FairPoor
Given (check all that apply):
Responsiveness to therapeutic techniques
Attendance and participation in therapy sessions
Compliance with caregiver training program/ home exercise program
Stable medical status
Achieved optimal functional potential
Unstable medical status
Other:
RECOMMENDATIONS
Recommendations are as follows:
Receive Speech Therapy:
See Attached for Plan of Care for Long Term Goals and Objectives
Duration: 6 Months
1 Year
Other:
Frequency: _times per week
Time:30 Minutes per session
45-60 Minutes per session are medically necessary:
Reason:
Therapy is not recommended at this time
Therapy is not indicated at this time but a Re-Evaluation is recommended in 6 months
Refer to:
Physician for consideration of:
Developmental Pediatrician and/or Neurology Clinical Psychology Evaluation
Applied Behavior Analysis Physical Therapy
Occupational Therapy
Audiological Evaluation for:
Other:
If you have any questions or concerns regarding this evaluation, please call Independent Living, Inc.- Pediatrics at (813) 963-6923.
______ / ______Therapist Signature / Date:
FL License #:
______ / ______
Supervisor Signature (if appropriate) / Date
FL License #:
Dear Physician,
If you agree with the treatment plan, please sign and date the report and mail/fax to Independent Living, Inc.- Pediatrics. Your signature will convert this report into a prescription.
______
Physician Signature Date
______
Medipass Authorization Number (if applicable)