Communication Evaluation: Suzie Que
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MIDP Report Format
Name:
Age: (report in months)
Parents:
Address:
Phone:
File:
DOB:
DOE:
Referral:
Code:
COMMUNICATION EVALUATION
The Receptive-Expressive Emergent Language Scale – Revised (REEL-2), a parent interview tool, was
administered to …….
The Birth to Three Checklist of Learning and Language Behavior…
The Rossetti Infant-Toddler Language Scale…
OBSERVATIONS
Suzie separated easily from her mother…..
Kathleen used gestures, vocalizations, and words to indicate her needs and wants. Her babbling and
jargon included use of the following consonants: /t, d, m, n/ and “sh.”
SUMMARY
Results of formal and informal observations indicated that … (This needs to be a statement of level of
functioning WITHOUT using test or subtest names.) Susie’s main means of communication appeared to
be….
STRENGTHS (These do NOT need to be in sentence form.)
1. Visually and auditorally observant of the environment.
2. Appropriate stimulation provided by the family.
3. Recognized names of familiar objects such as bottle, ball…
NEEDS (NOT in sentence form)
1. Imitation of non-speech and speech sounds.
2. Increased use of words or word approximations to label and request.
3. Appropriate response to location indicators such as “in” and “on.”
OUTCOMES (These are to be general; broad; long-range – as Goals on an IEP would be. May be child or
family oriented.)
1. To use words or word approximations to communicate wants and needs on a daily basis.
Communication Evaluation: Suzie Que
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OBJECTIVES (include only one or two per outcome; these do NOT contain criteria)
1. To understand words associated with daily routine
a. bye-bye
b. eat
c. go
2. To use gestures to request toys, foods, or beverages visible to him
ACTIVITIES (These may be development steps to reach the objectives; may resemble a task analysis; may
look like home activities; may be parent oriented)
1. When Suzie fusses or cries because she is hungry, hold her bottle or spoon in front of her. When
she quiets and/or reaches toward it, immediately present it to her, commenting that “You want
your bottle; here’s your bottle” or “Time to eat. You’re hungry.”
2. Place a favorite object slightly out of Suzie’s reach and wait for her to look at the object or reach
toward it. Move the object around to draw her attention to it if necessary. If she does not move
toward the toy, take her hand and move it to the toy, allowing her to get it.
RECOMMENDATIONS
1. Suzie should be enrolled in/continue to receive services through the Minot Infant Development
Program.
2. Suzie’s speech and language should be re-evaluated in six months.
3. Suzie should be referred to ….
4. Suzie should receive a full audiological evaluation …
5. Suzie’s parents should continue to stimulate her speech and language development….
______________________________
___________________________________
Date
YOUR NAME, Student Clinician
___________________________________
Clinical Supervisor’s Name & Credentials
This evaluation was completed by a graduate student clinician under the supervision of an ASHA
certified and ND Licensed Speech-Language Pathologist.