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Medicaid or ID Number
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Allergies:
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Diagnoses:
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Comments
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Last PCP Visit
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Comments
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Functional Limitations:
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Comments
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Activities:
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Mental Status:
• • •
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Comments
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Prognosis:
• • •
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Comments
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Rehab Potential:
• • •
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Comments
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Speech Therapy Recommendations:
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Comments
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Speech Therapy Duration:
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Comments
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Modalities:
• • •
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Initial Behavior/Response:
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LANGUAGE
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Tests/Measures Used For Assessment of Language:
• • •
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Results of Language Assessment:
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ARTICULATION
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Measures Used For Assessment of Speech/Oral func
• • •
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articulation skills could
• • •
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Results of Speech and Oral Motor Assessment:
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OTHER
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Feeding Skills:
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Comment
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Fluency and Voice:
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Comments
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Hearing and Vision:
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Comments
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Assistive and Adaptive Devices:
• • •
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Other
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GOALS AND PLAN
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Long Term Goals: will clearly communicate
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will gain appropriate weight
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Short Term Goals:
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Summary
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Diagnosis
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and
• • •
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Speech/Language Delay
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will benefit from skilled speech therapy services
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Overall delay is-
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Intervention Plan:
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Discharge Plan:
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MD Signature
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TP2
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TP2 Page 2
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Superior Prior Auth
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TP1 - Betsy
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Additional Documents
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