UNT Speech and HearingCenter

Semester Therapy Report

Patient’s Name: Date of Report:

Address: Birthdate:

Age:

Parents:

History:

Briefly document the client’s significant history including the following information as indicated:

  • CURRENT speech/language diagnosis and/or medical diagnosis or an update of any recent medical changes (find the most recent evaluation/current diagnosis).
  • Initial treatment date and brief history of treatment at UNT Speech and HearingClinic
  • Focus on therapy from the previous semester (do not list the goals, just a statement)
  • Any other treatment outside of UNT (including current or previous)
  • Any other significant information, such as enrollment in school, work history, recent change in status, etc.

Do not need to repeat the history section of the diagnostic report

Current Therapy Goals: Status:

(List all long-term goals) (exceeded/met/partially met/

not met/revised)

*If a goal is revised- list that goal and indicate that it was revised, then list the new, revised goal and what their current status is with the revised goal.

Summary of Progress:

This section should include (in paragraph form) a brief summary that describes the clients progress overall progress and includes the following:

  • Attendance (number of sessions attended)
  • Participation (cooperation/motivation)
  • Overall summary of progress (i.e. excellent, good, fair, limited, poor)
  • Discuss status of each goal

-Effective treatment approaches, techniques

-Continued problem areas

-Current performance level of each goal

  • Patient/family education, status/outcome of home programs
  • Coordination with other agencies (i.e. school, etc.)

The length of this section will vary case by case. Your objective in this section is to document clearly and concisely your assessment of the client’s progress (supported by achievement of goals) and the major issues related to treatment this semester.

Summary/Recommendations:

Include a diagnostic statement summarizing the patient’s current speech-language impairment and level of function. Describe how the impairment will limit person’s ability to successfully function within the environment. Clearly state why person needs continued therapy.

Describe recommended intensity of therapy (i.e. two times per week for 15 weeks, with reassessment for additional therapy based on progress).

List recommended goal areas for continued therapy (please do not write in behavioral format). The next therapist will use these recommendations to help develop further treatment plans.

______

Student Clinician, Degree Supervisor name, Degree, CCC-SLP

Graduate Student Clinician Speech-Language Pathologist

Clinical Supervisor

Updated 8/22/13