SPEECH AND LANGUAGE EVALUATION

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Penelope Sabrina Holmes
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SPEECH AND LANGUAGE EVALUATION Authorization Period: to Patient: Parents: Phone: Chronological Age: Adjusted Age (if appropriate): Date of Evaluation: Therapist: PCP: Facility: Address: Phone: Fax:

1 SPEECH AND LANGUAGE EVALUATION Authorization Period: to Patient: Parents: Phone: Chronological Age: Adjusted Age (if appropriate): Date of Evaluation: Therapist: PCP: Facility: Address: Phone: Fax: CC: Medicaid #: BACKGROUND INFORMATION/ MEDICAL HISTORY Medical Diagnosis: Prenatal/Birth History: Medical History: Developmental Milestones: Previous Therapy History: Current Additional Services: Hearing Status: Vision Status: Follow up: Current Educational Placement: Current Equipment Use: Current Medications: Allergies: Referral Source:

2 Accompanied by: Parental/Caregiver Concerns/Reason for Referral: ASSESSMENT INFORMATION Language Tests Administered in: Modifications to testing procedures included: Evaluation Methods Implemented to Assess Communication Skills: Formal Measures Informal 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: Raw Score Standard Score Percentile Age- Equivalent Severity Rating Auditory Comp. Expressive Comm. Total Language Comments: Test Name: Raw Score Standard Score Percentile Age- Equivalent Severity Rating Auditory Comp. Expressive Comm. Total Language Comments: Auditory Comprehension (Receptive Language): Strengths: Areas for Development: Oral Expression (Expressive Language): Strengths:

3 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: Informal Measures Used: Scores: Raw Score Standard Score Percentile Age Equivalent Severity Rating Conversational Intelligibility (connected speech): Phonemic Inventory (if appropriate): Phonological Processes (if appropriate): Articulation Errors/Distortions: Initial Position: Medial Position: Final Position: Blends: Refers to the quality and/or frequency of ones voice. VOICE No concerns noted at this time. Formal Measure: 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:

4 FLUENCY Refers to the flow and/or rate of speech. No concerns noted at this time. Unable to assess due to: Formal Measure: 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: 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

5 SPEECH/ LANGUAGE/FEEDING DIAGNOSIS (Listed in order of primary concerns) 1. _ 2. _ 3. THERAPEUTIC PROGNOSIS Excellent Good Fair Poor 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 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 Occupational Therapy Audiological Evaluation for: Physical Therapy Other: If you have any questions or concerns regarding this evaluation, please call Independent Living, Inc.- Pediatrics at (813) Therapist Signature Date: FL License #: Supervisor Signature (if appropriate) Date FL License #:

6 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)

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