Therapy Assessment / Evaluation Report
THERAPY ASSESSMENT / EVALUATION REPORT
|INDIVIDUAL’S NAME (Last, First, M.I.) |DATE OF BIRTH |ASSISTS NO. |
| | | |
|INDIVIDUAL’S ADDRESS (No., Street, City, State, ZIP) |
| |
|PROVIDER / AGENCY NAME |DATE OF ASSESSMENT |DATE OF REPORT |
| | | |
|PROVIDER / AGENCY ADDRESS (No., Street, City, State, ZIP) |
| |
|PHONE NO. (Include Area Code) |FAX NO. (Include Area Code) |DISCIPLINE / THERAPY |
| | |Occupational Speech Physical |
|CPT CODE (Optional) |DIAGNOSIS |SUPPORT COORDINATOR’S NAME |
| | | |
|RESPONSIBLE PERSON’S NAME |PHONE NO. (Include Area Code) |
| | |
|REASON FOR REFERRAL (BASED ON INDIVIDUAL’S / FAMILY’S CONCERNS, PRIORITIES AND RESOURCES; ISP / IFSP / PERSON-CENTERED PLAN OUTCOMES) |
| |
|REVIEW OF PERTINENT MEDICAL, EDUCATIONAL AND THERAPY REPORTS, DIAGNOSIS / BACKGROUND INFORMATION |
| |
|METHOD OF ASSESSMENT (FORMAL / INFORMAL TOOLS / ASSESSMENTS USED) |
| |
|INDIVIDUAL’S NAME (Last, First, M.I.) |DATE OF BIRTH |ASSISTS NO. |
|VALIDITY AND LIMITATIONS OF THIS ASSESSMENT |
| |
|SUMMARY AND CLINICAL IMPRESSIONS |
| |
|RECOMMENDED FUNCTIONAL GOALS, OUTCOMES, STRATEGIES AND ACTIVITIES FOR THE INDIVIDUAL, FAMILY OR CAREGIVERS |
| |
|RECOMMENDED FREQUENCY, LEVEL AND DURATION OF TREATMENT AND MODEL OF SERVICE DELIVERY BY THE THERAPIST (PARTICIPATION-BASED/ROUTINE BASED/CONSULTATIVE , GROUP, |
|1:1, EARLY INTERVENTION MUST BE IN NATURAL ENVIRONMENT) (INCLUDE ANY RECOMMENDED MONITORING OR OVERSIGHT BY THE THERAPIST FOR INDIVIDUAL, FAMILY, OR CAREGIVERS)|
| |
|INDIVIDUAL’S NAME (Last, First, M.I.) |DATE OF BIRTH |ASSISTS NO. |
|AS APPROPRIATE, RECOMMENDATIONS AND PURPOSE FOR EQUIPMENT (EXAMPLE: AUGMENTATIVE DEVICE) |
| |
|CAREGIVER SIGNATURE |
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|THERAPIST SIGNATURE |
| |
ROUTING: Original – Support Coordinator; Copy – Primary Care Physician; Copy – Family Rev. 11/09
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