Pediatric SLP Ax Report

Date of Birth: 15 March 2019 1 November 2024 Added by: Dr. Emily Carter, SLP, Reg. No. 123456, Speech Pathologist License #SLP78910 Signature Status: Signed Chronological Age: 5 years, 7 months Accompanied by: - Mother, Sarah Johnson Note: Location: - Sunshine Pediatric Clinic 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) Written consent obtained to exchange information with the following parties: - Pediatrician, Dr. John Smith Additional Notes: - Child is cooperative and attentive during sessions. BACKGROUND INFORMATION: - Birth History: Full-term, normal delivery - Medical History: No significant medical issues - Developmental Milestones: Achieved all milestones within normal range - Speech and Language Milestones: Delayed speech development - Daily Program: Attends preschool - Languages at home: English, Spanish - Hearing: Passed newborn hearing screening - Other Services Involved or Waiting for: Occupational therapy - Siblings: One older brother Reported Concerns: - Difficulty with articulation and phonology Method of Assessment: - Standardized speech and language assessments SOCIO-COMMUNICATION SKILLS: - Engages well with peers and adults - Test Administered and results: CELF-P2, below average in expressive language PLAY SKILLS: - Engages in imaginative play BEHAVIOUR: - Generally well-behaved, occasional frustration with communication RECEPTIVE LANGUAGE SKILLS: - Understands simple instructions - Test Administered and results: PPVT-4, average range EXPRESSIVE LANGUAGE SKILLS: - Limited vocabulary, difficulty forming sentences - Test Administered and results: EVT-2, below average - Language Sample: "I want play car." - MLU: 3.0 - Sample: "Me go park." ARTICULATION/PHONOLOGY/MOTOR SPEECH: - Difficulty with /r/ and /s/ sounds - Test Administered and Results: GFTA-3, below average FLUENCY OF SPEECH: - Occasional repetitions noted VOICE: - Normal pitch and volume RECOMMENDATIONS & SUMMARY: - Recommend speech therapy twice a week - In summary, child presented with: Articulation and expressive language delays Tentative Goals for Therapy: - Goal: Improve articulation of /r/ and /s/ sounds - Goal: Increase expressive vocabulary - Goal: Enhance sentence structure - Goal: Develop social communication skills - Goal: Reduce frustration during communication PLAN/FOLLOW-UP: - The above assessment results and recommendations have been discussed with the client's guardian.