Speech, Language, & Educational Associates
5067300-509270Speech/Language EvaluationPatient Name (Last, First)Date of Birth and AgeAddressHome/Cell Phone NumberEmail (if available)Date of Evaluation: Click here to enter text.Procedure: FORMCHECKBOX 92521: Evaluation of speech fluencyDiagnosis Code: Click here to enter text. FORMCHECKBOX 92522: Evaluation of speech production FORMCHECKBOX 92523: Evaluation of speech production with evaluation of language comprehension and expression FORMCHECKBOX 92524: Behavioral and qualitative analysis of voice and ResonancePresenting Problem:Background Information:Test Results/Information:Test(s) used for this evaluation(tests administered)Test ResultsInterpretation of ResultsRecommendations: FORMCHECKBOX Speech therapy ___/week for ___ (duration) FORMCHECKBOX Refer to: _____________________________ FORMCHECKBOX Other: _______________________________Long Term Goal(s)Short Term Goal(s) Other/Notes:Evaluation Completed by:Supervisor Information:SLP Name: Click here to enter text.Supervisor Name: Click here to enter text.License #: Click here to enter text.License #: Click here to enter text. ................
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