History

• Identifying information
• Referral Source and Chief Concerns
• Dates and locations of previous evaluations
• Medical/Birth History
• Developmental History
• Social/Educational History
• Previous Treatment

•  general behaviors
•  how well warmed-up to setting
•  how cooperative
•  validity of testing
•  oppositional behaviors/behaviors that interfered with testing

•  screening that we did
•  testing that was done by other agencies

• general comment on tests given or if informal measures were used

• Receptive Language

• test scores/interpretation
• informal observations (e.g., commands/semantic relations followed, question types answered, concepts understood etc,)
• Expressive Language

•   Form
•    formal measures (e.g., grammatic closure tests, sentence imitation)
•    MLU
•    word order/syntactic structure/grammatical morphemes

  

• Content

•  topics discussed (here/now; past, present future events
•  appropriateness of language to context vs tangential or echolalic language
•  perseverative language
•  semantic relations
•  vocabulary
•  narrative skills

• Use

• communicative intentions
• eye contact/physical proximity and body language
• topic initiation, maintenance, conclusion
• measures (e.g., Prutting checklist)
• turn taking skill

Speech/Articulation

•     Conversational speech
• sound errors
• intelligibility
• Identification and analysis of sound errors
• Consistency of sound errors
• Patterns of sound errors
• errors types
• severity of errors
• phonological processes
• Rate, prosody, intonation, inflection, etc.
• Structural/Functional Evaluation
• Stimulability/Readiness for learning information

Voice

• Quality
• hoarse
• aphonic
• Pitch
• too high
• too low
• variable
• Resonance
• nasal
• denasal
• mixed
• Breath support; type of breathing used
• diaphragmatic
• thoracic
• clavicular
• Muscular tension
• Stimulability of improved voice

Fluency

• Types and frequencies of dysfluencies
• Associated motor behaviors
• hand movements
• eyeblinking
• Avoidance of sounds, words, or situations; anticipation of stuttering
• Speech rates with and without dysfluencies
• Stimulability of fluent speech

•  Play/Cognitive behaviors
• low structured play behaviors
• cognitive screenings (e.g., Boyd)
• Preliteracy

• motor and coordination

• Statement of diagnosis
• Concise statement of mose significant findings
• Prognosis

Recommendations

• no treatment, put on our waitlist or refer out
• if treatment is recommended - what should be targeted
• things parents and/or other professionals can do
• referrals to other agencies

NOTES:

1.  Be careful not to make blanket statements that are not backed up with data. For example, rather than stating:

"Informal observations indicated normal comprehension."

What were the behaviors that you saw or probed that told you comprehension was normal. For example:

"Sally was observed to follow multi-step directions, answer a variety of questions, and appropriately and contingently respond during conversation suggesting that her comprehension was age-appropriate."

2.  Include a cover letter with your report as a courtesy.

3.  Provide spaces for yourself and for your supervisor to sign.

4.  If you are giving me hard copies of reports - please double space your initial drafts.
 

 

Home