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-28575-533400ghPhone (813) 963-6923 Fax (813) 200-8659SPEECH AND LANGUAGE THERAPY RE- EVALUATION & PLAN OF CARE (if applicable)Patient: PCP: DOB: Facility: Parents: Address: Phone: Chronological Age: Phone: Adjusted Age (if appropriate): Fax: Date of Re- Evaluation: CC: Therapist: Medicaid #: UPDATED BACKGROUND INFORMATION/ MEDICAL HISTORYCurrent Medical Diagnosis: Prenatal/Birth History: Updated Medical History: Developmental Milestones: Rolling: Walking: Sitting: First Words: Crawling: Potty Training: Previous Therapy History: Current Additional Services: Current Hearing Status: Current Vision Status: Current Educational Placement: Current Equipment Use: Current Medications: Allergies: Referral Source: Accompanied by: Parental/Caregiver Concerns: ASSESSMENT INFORMATIONLanguage Tests Administered in: Choose an item.Modifications to testing procedures included: Evaluation Methods Implemented to Assess Communication Skills: FORMCHECKBOX Formal Measures FORMCHECKBOX Informal MeasuresInformal Measures Included: FORMCHECKBOX Caregiver Report FORMCHECKBOX Clinical ObservationBehavioral Observations: LANGUAGE DEVELOPMENT FORMCHECKBOX Within normal limits for ageAreas 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 ScoreStandard ScorePercentileAge- EquivalentSeverity RatingAuditory Comp. Expressive Comm. Total Language Comments: Test Name: Choose an item.Raw ScoreStandard ScorePercentileAge- EquivalentSeverity RatingAuditory Comp. Expressive Comm. Total Language Comments: Click here to enter text. Auditory Comprehension (Receptive Language):Strengths: Areas for Development: Oral Expression (Expressive Language):Strengths: Areas for Development: Additional Assessment Information: ORAL MOTOR FUNCTION/STRUCTURE FORMCHECKBOX A cursory oral peripheral examination was unremarkable. All oral structures and musculature appear intact for speech and feeding. FORMCHECKBOX Unable to assess due to: FORMCHECKBOX Fatigue FORMCHECKBOX Compliance FORMCHECKBOX Other: FORMCHECKBOX A cursory oral peripheral examination revealed: Functional Skills Affected: FORMCHECKBOX Articulation/ Speech FORMCHECKBOX Feeding/Swallowing FORMCHECKBOX Other: ARTICULATIONRefers to way sounds are produced and/or sequenced together. FORMCHECKBOX Within normal limits for age FORMCHECKBOX Unable to formally assess due to: Choose an item.Formal Measures Used: Choose an rmal Measures Used: Scores: Choose an item.Raw ScoreStandard ScorePercentileAge EquivalentSeverity Rating Conversational Intelligibility (connected speech): Phonemic Inventory (if appropriate): Phonological Processes (if appropriate): Articulation Errors/Distortions:Initial Position: Medial Position: Final Position: Blends: Additional Comments: VOICERefers to the quality and /or pitch of ones voice. FORMCHECKBOX No concerns noted at this time. FORMCHECKBOX Formal Measure: Choose an item. FORMCHECKBOX Unable to assess due to: Choose an item.Indicate and describe areas of concern: FORMCHECKBOX Vocal Quality: FORMCHECKBOX breathy FORMCHECKBOX shrill FORMCHECKBOX hoarse FORMCHECKBOX harsh FORMCHECKBOX weak FORMCHECKBOX glottal fry FORMCHECKBOX no voice FORMCHECKBOX other: FORMCHECKBOX Pitch: FORMCHECKBOX too high FORMCHECKBOX too low FORMCHECKBOX monotone FORMCHECKBOX other: Additional Comments: FLUENCYRefers to the flow and/or rate of speech. FORMCHECKBOX No concerns noted at this time. FORMCHECKBOX Unable to assess due to: Choose an item. FORMCHECKBOX Formal Measure: Choose an item.Indicate and describe areas of concern: FORMCHECKBOX Rate of Speech: FORMCHECKBOX too fast FORMCHECKBOX too slow FORMCHECKBOX other: Description of dysfluencies: Secondary Behaviors: Percentage of speech affected: Severity Rating: Additional Comments: FEEDING / SWALLOWING SKILLSFeeding History (include MBS results): Means of Intake: FORMCHECKBOX Bottle Fed FORMCHECKBOX Open Cup FORMCHECKBOX Breast Fed FORMCHECKBOX Sipper Cup FORMCHECKBOX Straw FORMCHECKBOX Tube Fed FORMCHECKBOX Utensils (spoon and/or fork) FORMCHECKBOX Self- feedsCurrent Diet: FORMCHECKBOX Puree Food (stage 1) FORMCHECKBOX Junior Food (stage 2/3) FORMCHECKBOX Semi -Solids FORMCHECKBOX Table FoodsComments: Non-Nutritive Suck (if appropriate): FORMCHECKBOX normal FORMCHECKBOX abnormalDescribe: Nutritive Feeding Skills (if appropriate): FORMCHECKBOX normal FORMCHECKBOX abnormalDescribe: Feeding Concerns/Observations: UPDATED ASSESSMENT INFORMATION/ PROGRESS SUMMARY SPEECH/ LANGUAGE/FEEDING DIAGNOSIS(Listed in order of primary concerns)Choose an item/delete if not usingChoose an item/delete if not usingChoose an item/delete if not usingATTENDANCE/ PARTICIPATIONAttendance during previous authorization period was: FORMCHECKBOX Good (>80%) FORMCHECKBOX Fair (60-80%) FORMCHECKBOX Poor (<60%) If Fair or Poor, explain: FORMCHECKBOX Unable to document/data not available Why: Patient participation/compliance during treatment sessions: FORMCHECKBOX Excellent FORMCHECKBOX Good FORMCHECKBOX Fair FORMCHECKBOX PoorDescribe: CAREGIVER TRAINING PROGRAMDescription of home program/caregiver training program implemented during previous authorization period: Click here to enter text.Adherence to caregiver training/ home exercise plan: FORMCHECKBOX Excellent FORMCHECKBOX Good FORMCHECKBOX Fair FORMCHECKBOX PoorExplain: Skilled therapy services continue to be indicated to carryout plan of care because : UPDATED THERAPEUTIC PROGNOSIS FORMCHECKBOX Excellent FORMCHECKBOX Good FORMCHECKBOX Fair FORMCHECKBOX PoorGiven (check all that apply): FORMCHECKBOX Responsiveness to therapeutic techniques FORMCHECKBOX Attendance and participation in therapy sessions FORMCHECKBOX Compliance with caregiver training program/ home exercise program FORMCHECKBOX Stable medical status FORMCHECKBOX Achieved optimal functional potential FORMCHECKBOX Unstable medical status FORMCHECKBOX Other: RECOMMENDATIONSRecommendations are as follows: FORMCHECKBOX Continue to Receive Speech Therapy as skilled services are necessary to carryout POC because it requires one-on-one instruction from a skilled therapist due to the need for continually updated goals and techniques that cannot be provided by this patient’s caregiver at home. Patient and caregiver will follow-up with a home program that is designed to aid in appropriate carryover. FORMCHECKBOX See Attached for Plan of Care (POC) FORMCHECKBOX Continued therapy is not recommended at this time. FORMCHECKBOX Due to change in rehabilitative potential transition to consultative services/home maintenance program recommended. FORMCHECKBOX Therapy is not indicated at this time but a Re-Evaluation is recommended in 6 months; no POC required at this time. FORMCHECKBOX Refer to: FORMCHECKBOX Physician for consideration of: FORMCHECKBOX Developmental Pediatrician and/or Neurology FORMCHECKBOX Behavioral and/or Psychological Intervention Services. FORMCHECKBOX Audiologist for: FORMCHECKBOX Occupational Therapy FORMCHECKBOX Physical Therapy FORMCHECKBOX Other: If you have any questions or concerns regarding this evaluation, please call Independent Living, Inc.- Pediatrics at (813) 963-6923 or fax us at (813) 200-8659._______________________________________________________________________Therapist SignatureDate:FL License #: __________________________________________________________________________Supervisor Signature (if appropriate)DateFL License #: ................
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