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Speech-Language Pathology Annual Re-Evaluation and Progress Report NAME: SERVICE DATES: ADDRESS: REPORT DATE: DOB: SS#: CA: Case Manager: SPEECH-LANGUAGE PATHOLOGIST: , CCC-SLP -----------------------------------------------------------------------------------------------------------------ANNUAL RE-EVALUATION REPORT Medical Diagnoses: New Medical Information: as it relates to the scope of service Living, Day Activity and/or Working Circumstances New info, as it relates to the scope of service Outside Clinics, Audits or Evaluations: Describe the IDT's response as it relates to your scope of service Assessments Tools: Describe those utilized for re-eval or describe the assessment process Summary of Assessment Findings and Interpretations: At a minimum include primary language, expressive and receptive communication modalities and functional status, pragmatic communication function, eating and oral-motor issues and aspiration risk status. There may be other areas of functional assessment that are relevant to the individual. This eval is not expected to be as comprehensive as the initial evaluation. Recommendations: Include need for ongoing therapy, general goals and what service models would be beneficial to treatment ANNUAL SPEECH THERAPY PROGRESS REPORT Current Therapy Goals and Objectives: Identify Status of Therapy Goals and Objectives: In this section state whether each therapy objective is accomplished, on going, or no progress and include a narrative description of the current status. Data collection/outcome measures may be reported in this section. Integration of Therapy into the ISP: This section should report how therapy goals/objectives are related to and support the individual's ISP visions (Live, Work/Learn, Have Fun/Develop Relationships, Other) and their

Developmental Disabilities Supports Division ­ Clinical Services Bureau ­ SLP Sample Annual Program Report

Name Annual SLP Re-Eval and Progress Report

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desired outcomes and action plans. The therapist should describe how their service contributes to the successful implementation of the ISP. Current Written Support Plans: Identify Staff Training Provided (use dates of the 6-months covered by the report): Identify Assistive Technology Supported by SLP: Identify RECOMMENDATIONS: Recommend specific therapy goals and objectives to be addressed in therapy based upon the re-evaluation. These may be new, modified or discontinued goals/obj. The therapy goals and objectives that are related to the ISP are not known as of the writing of this report, but they will be known after the ISP meeting (and should be included in the Therapy Intervention Plan). Identify new or modified or discontinued written support plans. Identify new needed referrals or services. Identify new or modified or discontinued assistive technology. Identify the total need for therapy service hours/units for each model of therapy [integrated (individual/group) or clinical (individual/group)] to implement the anticipated treatment plan. Because the case manager will be developing the initial budget of up to 58-hrs/232-units, it would be helpful to identify how you would like those hours divided among the models of therapy. IF you know that you are going to request a clinical exception, the therapist may also identify that they will be asking for additional hours through that process. IT IS UNDERSTOOD THAT THE THERAPIST MAY NOT KNOW EXACTLY HOW MANY HOURS OF SERVICE ARE NEEDED TO IMPLEMENT THE INTERVENTION PLAN SINCE THIS REPORT IS WRITTEN PRIOR TO THE ISP MEETING. THIS IS OKAY. THE PLAN WILL IDENTIFY THE ADDITIONAL GOALS AND THE REQUEST FOR HOURS MAY BE MODIFIED WITH A REQUEST TO THE CASE MANAGER AND/OR A REQUEST FOR A CLINICAL EXCEPTION. __________________________ name, CCC-SLP Speech-Language Pathologist XC: , guardian , Case Manager, , Residential Services Coordinator, , Day Habilitation Services Coordinator, , Occupational Therapist , Physical Therapist , Behavior Therapist


Developmental Disabilities Supports Division ­ Clinical Services Bureau ­ SLP Sample Annual Program Report



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