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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