Last name, first name
DOB
SPEECH AND LANGUAGE RE- 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
See Initial Evaluation for Birth/Medical/Developmental History
Updated Status Changes:
Current Equipment Use:
Current Medications:
Allergies:
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:
Formal Measures Used: Choose an item.
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 the quality and /or pitch 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.
UPDATED ASSESSMENT INFORMATION/ PROGRESS SUMMARY
SPEECH/ LANGUAGE/FEEDING DIAGNOSIS
(Listed in order of primary concerns)
ATTENDANCE/ PARTICIPATION
Attendance during previous authorization period was:
Good (>80%) Fair (60-80%) Poor (<60%)
If Fair or Poor, explain:
Unable to document/data not available Why:
Patient participation/compliance during treatment sessions:
Excellent Good Fair Poor
Describe:
CAREGIVER TRAINING PROGRAM
Description of home program/caregiver training program implemented during previous authorization period:
Adherence to caregiver training/ home exercise plan:
Excellent Good Fair Poor
Explain:
Skilled therapy services continue to be indicated to carryout plan of care because:
UPDATED 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:
Continue with Speech Therapy:
See Attached 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:
Continued therapy is not recommended at this time.
Due to change in rehabilitative potential transition to consultative services/home maintenance
program recommended.
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 Audiologist for:
Occupational Therapy Physical Therapy
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)