| ID | Date | Type | Evaluation Diagnosis |
26450 | 03-04-2026 | Speech Initial Evaluation | F84.0, F80.2 | | Speech Background History: Noe is a 5;1 year old male who was seen on the above date for an initial evaluation per referral of his PCP to determine his current level of functioning and if skilled speech intervention is warranted at this time. Patient has a medical diagnosis of Autism Spectrum Disorder (ICD-10: F84.0). Noe lives with his mother. The primary language of the home is Spanish. Based on the home language, all testing was conducted in Spanish by a Bilingual Speech Language Pathologist. If patient is deemed appropriate for skilled speech and language intervention, it is recommended that therapy be conducted in Spanish. Patient was accompanied to the initial evaluation by his mother, who provided written and oral information referenced in this report.
Mother reported that Noe was recently diagnosed with Autism through his school district and that he has not previously received any therapy services. She also reported a family history of developmental delay. Mother expressed concerns regarding limited verbal output, stating that Noe does not speak at home and was significantly delayed in the emergence of his first words. She reported that he is not yet combining words to form sentences. At this time, Noe’s primary means of communication consists of gestures and hand leading to communicate his wants and needs.
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| Speech Medical History: |
| Speech Medications: None |
| Speech Behavioral Observations: Attending Skills: Distractible, Response Rate: Moderate delays, Level of Activity: Active, Cooperation: Active, Communicative Intent: With some prompts, Awareness of Others: Present, Reliability of Scores: Adequate, Awarencess of Environmental Events: Good, Social Interactions: Usually, Prognosis for Improved Communicative Functioning: Friendly, |
| Speech Communication Strengths: Appropriate use of eye contact, Auditory and visually alert and attentive, Follows verbal command with cues, Responds to greetings, |
| Speech Communication Weaknesses: Diminished vocabulary, Immediate echolalia, Perseverations, Repetitiveness, Self stimulation behaviors, Unable to answer questions, Unable to participate in a conversation, |
| Speech Background Summary: During the evaluation, Noe’s pragmatic skills were characterized by reduced attention to structured tasks and a preference for movement-based engagement. Upon entering the room, he was observed to roam around the environment and intermittently sit on the floor. He was prompted to sit at the table to participate in evaluation activities and transitioned to the table, remaining seated for longer periods when provided with a preferred item to fidget with. Parent report is consistent with these observations, as mother shared that Noe demonstrates a short attention span at home and benefits from having an object in his hands to support engagement. She reported that he is frequently active, prefers to stay busy, and does not typically remain seated for extended periods of time. |
| Speech Diagnosis/Impressions: Based on standardized assessments, parent interview, and skilled clinical observation, Noe presents with a SEVERE MIXED RECEPTIVE-EXPRESSIVE LANGUAGE DISORDER. Speech therapy is strongly recommended at this time, as Noe's communication skills are significantly below age expectations. Without skilled speech-language intervention, Ian’s safety risk is elevated, as his limited receptive language skills may impact his ability to understand directions and safety commands, and his expressive language deficits may prevent him from effectively communicating wants, needs, discomfort, or distress. Therapy will be conducted in Spanish, as this is Noe's primary language of exposure, to ensure effective skill acquisition and generalization within his natural environment. |
| Speech Diagnosis/Impressions: Based on standardized assessments, parent interview, and skilled clinical observation, Noe presents with a SEVERE MIXED RECEPTIVE-EXPRESSIVE LANGUAGE DISORDER. Speech therapy is strongly recommended at this time, as Noe's communication skills are significantly below age expectations. Without skilled speech-language intervention, Ian’s safety risk is elevated, as his limited receptive language skills may impact his ability to understand directions and safety commands, and his expressive language deficits may prevent him from effectively communicating wants, needs, discomfort, or distress. Therapy will be conducted in Spanish, as this is Noe's primary language of exposure, to ensure effective skill acquisition and generalization within his natural environment. |
| Speech Recommendations: Speech Therapy: 2 time(s) a Week for 30 to 45 minute sessions |
| ID | Plan of Care |
| 59032 | | Plan Date: 03-04-2026 | | Speech Assessment Summary: Based on standardized assessments, parent interview, and skilled clinical observation, Noe presents with a SEVERE MIXED RECEPTIVE-EXPRESSIVE LANGUAGE DISORDER. Speech therapy is strongly recommended at this time, as Noe's communication skills are significantly below age expectations. Without skilled speech-language intervention, Ian’s safety risk is elevated, as his limited receptive language skills may impact his ability to understand directions and safety commands, and his expressive language deficits may prevent him from effectively communicating wants, needs, discomfort, or distress. Therapy will be conducted in Spanish, as this is Noe's primary language of exposure, to ensure effective skill acquisition and generalization within his natural environment. | | Speech Rehabilitation Potential: Good. with consistent Speech Therapy and parental support | | Speech and Language Long Term Goals: | | Category | Goal Description | | Home Management Intervention Program | When counseled by the clinician, parents will incorporate the home management intervention program as a daily and weekly activity to transfer skills learned in therapy into the home environment. Home management training will optimize patients functional communication tasks in the home. | | Receptive Language | Within 12 months, Noe will demonstrate appropriate receptive language skills with 70% accuracy in order to omprove his overall understanding with peers and caregivers. | | Expressive Language | Within 12 months, Noe will demonstrate appropriate expressive language skills with 70% accuracy in order to increase his overall communication for ADLs. |
| | Speech and Language Short Term Goals: | | Category | Goal Description | | Expressive Language | Within 6 months, Noe will produce core vocabulary via total communication (e.g., AAC, signs, words) across a variety of pragmatic functions (e.g., requesting, protesting, commenting, gaining attention) in 5 out of 10 opportunities with moderate multimodal cues across 3 consecutive sessions to facilitate communication in social and/or emergency situations. | | Receptive Language | Within 6 months, Noe will answer simple yes/no and “wh-” questions (e.g., what, where) using total communication (e.g., AAC, signs, words) in 5 out of 10 opportunities with moderate multimodal cues across 3 consecutive sessions to facilitate communication in social and/or emergency situations. | | Receptive Language | Within 6 months, Noe will follow 1–2 step directions during structured and play-based activities with 50% accuracy with moderate multimodal cues across 3 consecutive sessions to facilitate communication in social and/or emergency situations. | | Expressive Language | Within 6 months, Noe will produce 2–3 word combinations during structured and play-based activities in 5 out of 10 opportunities with moderate multimodal cues across 3 consecutive sessions to facilitate communication in social and/or emergency situations. | | Expressive Language | Within 6 months, Noe will label common objects and actions during play and picture-based tasks in 5 out of 10 opportunities with moderate multimodal cues across 3 consecutive sessions to facilitate communication in social and/or emergency situations. |
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