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 |

|      |

|THERAPIST SIGNATURE |

|      |

ROUTING: Original – Support Coordinator; Copy – Primary Care Physician; Copy – Family Rev. 11/09

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