Comprehensive SLP Assessment

Chief Complaint

Consult Letter Template

Template

Date of Birth: [Patient Date of Birth] [Service Date] Added by: [Clinician Name], [Clinician Credentials], Reg. No. [Registration Number], [Clinician Specialty] License # [License Number] Chronological Age: [Patient Age] Accompanied by: [Accompanying Person(s)] Location: [Clinic Name] CONSENTS: - Assessment procedures, benefits, risks, side effects, alternative courses of action, and likely consequences of not having the service explained to healthcare decision maker and verbal consent obtained for assessment as described. - Fee Schedule explained and agreed to in previous communication and documented in chart notes. - Online Intake--Collection, Retention and Maintenance of health information as per PHIPA signed. - Online Intake--Email waiver signed through Online Intake allowing for communication regarding client through e-mail. - Online Intake--Consent to Exchange Information with Insurance Company (as applicable) BACKGROUND INFORMATION: - Birth History: [Birth History] - Medical History: [Medical History] - Developmental Milestones: [Developmental Milestones] - Speech and Language Milestones: [Speech and Language Milestones] - Daily Program: [Daily Program] - Languages at home: [Languages Spoken at Home] - Hearing: [Hearing Status] - Other Services Involved or Waiting for: [Other Services] - Siblings: [Sibling Information] Reported Concerns: - [Reported Concerns] Method of Assessment: - [Method of Assessment] SOCIO-COMMUNICATION SKILLS: - [Socio-communication skills description] - Test Administered and results: [Test Name], [Test Results] PLAY SKILLS: - [Play skills description] BEHAVIOUR: - [Behaviour description] RECEPTIVE LANGUAGE SKILLS: - [Receptive language skills description] - Test Administered and results: [Test Name], [Test Results] EXPRESSIVE LANGUAGE SKILLS: - [Expressive language skills description] - Test Administered and results: [Test Name], [Test Results] - Language Sample: [Language Sample] - MLU: [Mean Length of Utterance] - Sample: [Sample Utterance] ARTICULATION/PHONOLOGY/MOTOR SPEECH: - [Articulation/Phonology/Motor Speech description] - Test Administered and Results: [Test Name], [Test Results] FLUENCY OF SPEECH: - [Fluency of speech description] VOICE: - [Voice description] RECOMMENDATIONS & SUMMARY: - [Recommendations] - In summary, child presented with: [Summary of Presentation] Tentative Goals for Therapy: - Goal: [Goal 1] - Goal: [Goal 2] - Goal: [Goal 3] - Goal: [Goal 4] - Goal: [Goal 5] PLAN/FOLLOW-UP: - The above assessment results and recommendations have been discussed with the client's guardian.