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
Last name, first name
DOB
Language Tests Administered in: Choose an item:
Modifications to testing procedures included:
Evaluation Methods Implemented to Assess Communication Skills:
Formal Measures
Informal Measures
Informal Measures Included:
Caregiver Report
Clinical Observation
Formal measure not administered due to:
Behavioral Observations:
LANGUAGE DEVELOPMENT
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:
Within normal limits.
Test Name: Choose an item:
Raw Score
Standard
Percentile
Age- Equivalent Severity Rating
Score
Auditory Comp.
Choose an item:
Expressive
Comm.
Choose an item:
Total Language
Choose an item:
Comments:
Test Name: Choose an item:
Raw Score
Standard
Score
Percentile
Age- Equivalent
Severity Rating
Auditory Comp.
Choose an item:
Expressive
Comm.
Choose an item:
Total Language
Choose an item:
Comments:
Auditory Comprehension (Receptive Language):
Strengths:
Areas for Development:
Oral Expression (Expressive Language):
Strengths:
Areas for Development:
Additional Assessment Information:
Last name, first name
DOB
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: choose item:
Informal Measures Used:
Formal Measures Used: Choose an item:
Scores:
Raw Score
Standard Score
Percentile
Age Equivalent
Severity Rating
Choose an item:
Conversational Intelligibility (connected speech):
Phonemic Inventory (if appropriate):
Phonological Processes (if appropriate):
Articulation Errors/Distortions:
Initial Position:
Medial Position:
Final Position:
Blends:
Additional Comments:
VOICE
No concerns noted at this time.
Formal Measure: Choose an item:
Unable to assess due to: choose item:
Indicate and describe areas of concern:
Vocal Quality:
breathy
shrill
hoarse
no voice
other:
Pitch:
too high
too low
monotone
Additional Comments:
harsh
other:
FLUENCY
Refers to the flow and/or rate of speech.
No concerns noted at this time.
Unable to assess due to: choose item:
Formal Measure: Choose an item:
Indicate and describe areas of concern:
Rate of Speech:
too fast
too slow
other:
weak
glottal fry
Last name, first name
DOB
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
Utensils (spoon and/or fork)
Self- feeds
Current Diet:
Puree Food (stage 1)
Junior Food (stage 2/3)
Semi -Solids
Comments:
Feeding /Swallowing skills are:
within functional limits for age.
of concern. Feeding/Swallowing Evaluation recommended.
Tube Fed
Table Foods
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
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 Plan of Care for Long Term Goals and Objectives
Duration:
6 Months
Last name, first name
DOB
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
Refer for 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)
FL License #:
Date
Last name, first name
DOB
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
_________________________________
Medipass Authorization Number (if applicable)
__________________
Date