SPEECH-LANGUAGE THERAPY SERVICES SESSION NOTES
SPEECH THERAPY SHARS LOGS
Student Name: ______________________________ DOB: _______________ Medicaid #: _______________
Practitioner: _______________________________________ SLP-CCC____ SLP Intern/CFY____ SLP____
Physician & Date of RX: _______________________________ ASLP____ TX. Lic. SLP____ TEA Cert ____
Parental Consent Date: __________________________School District/CO-OP: _______________________
|Date: __________________ |Date: __________________ |Date: __________________ |Date: __________________ |Date: __________________ |
|Start Time: _____________ |Start Time: _____________ |Start Time: _____________ |Start Time: _____________ |Start Time: _____________ |
|Stop Time: _____________ |Stop Time: _____________ |Stop Time: _____________ |Stop Time: _____________ |Stop Time: _____________ |
|Units Service Code |Units Service Code |Units Service Code |Units Service Code |Units Service Code |
|____ I – Individual |____ I – Individual |____ I – Individual |____ I – Individual |____ I – Individual |
|____ G – Group |____ G – Group |____ G – Group |____ G – Group |____ G – Group |
|____ E – Evaluation |____ E – Evaluation |____ E – Evaluation |____ E – Evaluation |____ E – Evaluation |
| | | | | |
|Re-Eval ____ |Re-Eval ____ |Re-Eval ____ |Re-Eval ____ |Re-Eval ____ |
|Initial – Eval ____ |Initial – Eval ____ |Initial – Eval ____ |Initial – Eval ____ |Initial – Eval ____ |
| | | | | |
|Qualify: Y ___ N ___ |Qualify: Y ___ N ___ |Qualify: Y ___ N ___ |Qualify: Y ___ N ___ |Qualify: Y ___ N ___ |
| | | | | |
|Initials: _____ |Initials: _____ |Initials: _____ |Initials: _____ |Initials: _____ |
|Objectives |Objectives |Objectives |Objectives |Objectives |
|A L F V PL PH |A L F V PL PH |A L F V PL PH |A L F V PL PH |A L F V PL PH |
|Aug |Aug |Aug |Aug |Aug |
|IEP # |IEP # |IEP # |IEP # |IEP # |
|1 2 3 4 5 6 ____ |1 2 3 4 5 6 ____ |1 2 3 4 5 6 ____ |1 2 3 4 5 6 ____ |1 2 3 4 5 6 ____ |
|Activities |Activities |Activities |Activities |Activities |
|____ Worksheets |____ Worksheets |____ Worksheets |____ Worksheets |____ Worksheets |
|____ Manipulative |____ Manipulative |____ Manipulative |____ Manipulative |____ Manipulative |
|____ Picture Cards |____ Picture Cards |____ Picture Cards |____ Picture Cards |____ Picture Cards |
|____ Word List |____ Word List |____ Word List |____ Word List |____ Word List |
|____ Games |____ Games |____ Games |____ Games |____ Games |
|____ Computer |____ Computer |____ Computer |____ Computer |____ Computer |
|Other: |Other: |Other: |Other: |Other: |
| | | | | |
|Observations |Observations |Observations |Observations |Observations |
|___ Mastered |___ Mastered |___ Mastered |___ Mastered |___ Mastered |
|___ Progress |___ Progress |___ Progress |___ Progress |___ Progress |
|___ No Change |___ No Change |___ No Change |___ No Change |___ No Change |
|___ Regression |___ Regression |___ Regression |___ Regression |___ Regression |
|Other: |Other: |Other: |Other: |Other: |
| | | | | |
Objectives: A- Articulation L – Receptive & Express Skill F- Fluent Speech V-Vocal Quality/Response PL – Pre-language Skills PH- Phonology Aug- Augmentative Communication Skills
Practitioner’s Signature (Required): _______________________________
|Units: 1 Unit – 9-22 minutes | | |
| 2 Units – 23-37 minutes, etc |1-877-897-8283 |Supervisor’s Signature (Required for ASLP, Tx Lic SLP & TEA SLP) |
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