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Speech and Language Evaluation Report


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RESOURCE PACKET
For Speech/Language

Impairments

General Assessment




Speech and Language Evaluation Report



Name:


Sex:

Present Grade Placement:

Date of Birth: C. A.:

Examiner:

Present School:

Teacher:


Date of Evaluation:

I. Purpose of Evaluation

 This speech and language evaluation was requested to determine if the student meets the TN Department of Education eligibility standards as speech and/or language impaired.

 This is a reevaluation in order to determine if the student meets the TN Department of Education eligibility standards as speech and/or language impaired. (See reevaluation summary in student’s special education file.)



  • A speech and language evaluation was requested to gather more information to be used in planning the IEP.




II. History And Behavioral Observations

Relevant Developmental and Medical History:

_______________________________________________________________________________________________

_______________________________________________________________________________________________

Teacher Input and Teacher Observation forms are attached. Parent Information is attached.


Behavior Observations:

During the assessment the student was  Cooperative Attentive  Distracted Other________________________


Test results are considered valid.

Test results should be viewed with caution, as they may not indicate an accurate current level of communicative abilities.



Comments: ______________________________________________________________________________________

________________________________________________________________________________________________




III. Environmental Considerations and Dialectal Patterns

Is the student ELL or ESL?  Yes  No If yes — Is the child English Language Proficient?  Yes  No

Home Language (L1) ___________________________ Child’s Dominant Language ___________________________




IV. Hearing

 Pass  Fail Comments: _______________________________________________________


V. Speech Assessment

A. Articulation Test: ___________________________________________________________________________

Speech Sample: __________________________________________________________________


Intelligibility of conversational speech:

In known contexts  Good  Fair  Poor

In unknown contexts  Good  Fair  Poor

Stimulability for correct sound production  Good  Fair  Poor


A
Phonological Error Patterns

(Patterns checked should not be used by a child this age)
___ Initial consonant deletion (up for cup)

___ Final consonant deletion (do for dog)

___ Weak syllable deletion (tephone for telephone)

___ Intervocalic deletion (teephone for telephone)

___ Cluster reduction (sove for stove, cown for clown)

___ Voicing/Devoicing (bear for pear, koat for goat)

___ Stopping (tun for sun, pour for four)

___ Backing (kable for table)

___ Fronting (tup for cup, thun for sun)

___ Stridency deviation (soe for shoe, fumb for thumb)

___ Liquid simplication (wamp for lamp, wed for red)

___ Deaffrication (tair for chair, dump for jump)

___ Other: ____________________________________
rticulation Errors

Error sounds/patterns which were produced and which are

considered below normal limits for a child this age included the following:




Substitution

Deletion

Distortion

Initial










Medial










Final










Exhibited developmental speech sound errors affecting: _________________________________________________


No Apparent Articulation Problem Articulation Problem Indicated
Comments: _____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________


B. Oral Peripheral Exam: Oral structure and movement appear adequate for speech production

Deviations: _____________________________________________________________

_____________________________________________________________


  1. Voice: Test: ________________________________ Other: _________________________________

Appropriate for sex and age

Not Appropriate for sex and age

Comments/Characteristic: (see attached): ____________________________________________________________

________________________________________________________________________________________________________



  1. Fluency: Test: _______________________________ Other: _______________________________

Appropriate

Inappropriate



Student’s attitude about stuttering:

 See attached documentation

 Refer to Parent Information

Comments/Characteristics (see attached): __________________________________________________________

_____________________________________________________________________________________________




VI. Language Assessment:




Test: ____________________________________

Results: Receptive Score: _____________

Expressive Score: _____________

TOTAL SCORE: ______________


Test: ____________________________________

Results: _________________________________


Test: ____________________________________

Results: _________________________________


Total language score is:




Within 1.5 SD of the mean

Greater than 1.5 SD from the mean

There  is  is not a significant difference between receptive and expressive language scores.




Areas of Strength:

_____________________________________________

_____________________________________________

_____________________________________________



Areas of Weakness:

____________________________________________

____________________________________________

____________________________________________



Informal Language Sample reveals appropriate:



Sentence Length and Complexity (MLU) Yes No

Word Order

(syntax)

Yes No


Vocabulary

(semantics)

Yes No


Word Form (morphology)

Yes No


Use of Language (pragmatics)

Yes No

Comments: ________________________________________________________________________________________________

___________________________________________________________________________________________________________
Functional Communication Assessment

Comments/Characteristics (see attached): ______________________________________________________________




VII. Effect on Educational Performance (Based on Data Collected)

  • Does not adversely affect educational performance.

  • Does adversely affect educational performance.

  • Evidence (grades, work samples, anecdotal information, etc.) are attached.




VIII. Diagnostic Impressions

This student DOES MEET the eligibility standards for the following impairment(s):

Language

Articulation

Fluency

Voice

This student DOES NOT MEET the eligibility standards for the following impairment(s):



Language

Articulation

Fluency

Voice


IX. Recommendations

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

This report is submitted to the IEP team for consideration when making decisions regarding placement and programming. Attach additional information to report.

_____________________________________________________

Speech-Language Therapist
Early Interventions Worksheet for Speech/Language


NOTE: When completed, this worksheet becomes part of the child’s educational records.

It should be completed prior to the child’s initial referral.

Child’s Name ______________________________ DOB ____________ Grade _______

School ____________________ Date __________ Teacher _______________________



  • The reason for request included concerns related to speech and/or language.

Yes  No 

Area(s) of Concern: ____________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________


  • The SLT and classroom teacher were active participants in early intervention process.

Yes  No 

If NO, explain: _________________________________________________________

_____________________________________________________________________

_____________________________________________________________________




  • A review of existing records indicated areas of concern related to communication.

Yes  No 
Check which records were reviewed:

Preschool (e.g., nursery, day care, early intervention)

Cumulative

School health

Other medical

Active/inactive special education

Other service providers (e.g., psychologist, social workers, Occupational Therapists,

Physical Therapists, private providers)


Other (describe) ____________________________________________________________

__________________________________________________________________________

Comments _________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________



(For ELL Students Only)

ELL Teacher was an active participant in early intervention process.

Yes No 

If NO, explain:


Home Language Survey was reviewed.

Yes No 


Home language is __________________________.
Native and English language dominance and language proficiency have been determined.

Yes No ___







Listening

Speaking

Reading

Writing

L1

Child is dominant in













L2

Child is dominant in













Comments:

Date of last hearing screening __________/ Results:______________________

Date of last vision screening __________/ Results:_______________________

Comments _________________________________________________________________



__________________________________________________________________________

__________________________________________________________________________
Observation of child was conducted. Yes No 

Comments _________________________________________________________________



__________________________________________________________________________

__________________________________________________________________________
Conversation was held with child. Yes No 

Comments _________________________________________________________________



__________________________________________________________________________

__________________________________________________________________________
Describe early intervention strategies and effectiveness of each.

    1. _____________________________________________________________________

    2. _____________________________________________________________________

    3. _____________________________________________________________________

    4. _____________________________________________________________________

    5. _____________________________________________________________________


If successful, the early intervention process is stopped. This does not preclude later referral for general education assistance or later referral to the IEP team. If the child is referred to Special Education, attach this report to the referral form.
Parent Input form – General

CONFIDENTIAL
Student Information

Name ______________________ Form completed by _____________________Date _________

Date of birth __________ Age _________
Parents/Legal Guardians (Check all that apply.)


  1. With whom does this child live?

    Both parents

     Mother

     Father

     Stepmother

     Stepfather

     Other ___________________________________________________________

  2. Parents’/Legal Guardians’ Name ___________________________________________________

Address ______________________________________________________________________

Home phone ____________ Work phone ____________ Cell phone _____________

List names and relationships of people at home ________________________________________


  1. Are there any languages other than English spoken at home?  Yes  No

If yes, what languages? ____________ By whom____________ How often? _____________

  1. Areas of Concern (Check all that apply.)

     Behavioral/emotional

     Slow development

     Listening

     Immature language usage

     Difficulty understanding language

     Health/medical

     Slow motor development

     Vision problems

    Uneven development

     Speech difficult to understand

     Stuttering

     Other: ___________________

  2. Why are you requesting this evaluation? ________________________________________________

_________________________________________________________________________________

  1. Did anyone suggest that you refer your child?  Yes  No

If yes, name and title ________________________________________________________________

  1. Has a physician, psychologist, speech pathologist or other diagnostic specialist evaluated your child?  Yes  No

  2. Was a diagnosis determined?  Yes  No

Please explain: ____________________________________________________________________
Preschool History (Check all that apply)

  1. Preschool/daycare programs attended

Name ______________________ Address ______________________ Dates__________________

Name ______________________ Address ______________________ Dates__________________



  1. List any special services that your child has received (e.g., Head Start, therapy, etc.):

Type of service __________ Age __________ Dates __________ School/agency ________________

Type of service __________ Age __________ Dates __________ School/agency ________________



  1. If your child has attended a preschool or daycare and problems were discussed with you about his/her behavior, explain what was tried and if you think it worked___________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Developmental History


  1. Pregnancy and Birth

Which pregnancy was this?  1st  2nd  3rd  4th Other_______ Was it normal?  Yes  No

Explain any complications ____________________________________________________________

Was your child –  Full term  Premature What was the length of labor? _____________________

Was the delivery – Induced?  Yes  No Caesarian?  Yes  No

Birth weight _______ Baby’s condition at birth (jaundice, breathing problems, etc.)_______________

_________________________________________________________________________________



  1. Motor Development (List approximate ages)

    Sat alone

    Crawled

    Stood alone

    Walked independently

    Fed self with a spoon

    Toilet trained: Bladder

    Bowel

  2. Medical History

List any significant past or present health problems (e.g., serious injury, high temperature or fever, any twitching or convulsions, allergies, asthma, frequent ear infections, etc.).

________________________________________________________________________________

List any medications taken on a regular basis ____________________________________________

________________________________________________________________________________

List medical treatments (e.g., PE tubes, inhalers, medications, ear wax removal) ________________

________________________________________________________________________________



  1. Speech and Language (List approximate ages.)

____________ Spoke first words that you could understand (other than mama or dada)

____________ Used two-word sentences

____________ Spoke in complete sentences

____________ Does your child communicate primarily using speech?

____________ Does your child communicate primarily using gestures?

____________ Is your child’s speech difficult for others to understand?

____________ Does your child have difficulty following directions?

____________ Does your child answer questions appropriately?



  1. Social Development

What opportunities does your child have to play with children of his/her age? __________________

______________________________________________________________________________

What play activities does your child enjoy? _____________________________________________

Does s/he play primarily alone?  Yes  No With other children?  Yes  No

Does s/he enjoy “pretend play?”  Yes  No

Do you have concerns about your child’s behavior?  Yes  No If yes, please explain:

______________________________________________________________________________

______________________________________________________________________________

How do you discipline your child? ___________________________________________________

Thank you for providing the above developmental information about your child. Please return to the Speech - Language Therapist at your child’s school. If you have any questions, please feel free to contact ___________________ at ___________________________________________________.


General Education Teacher’s Input

(Indirect Observation)



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