Patient Name: Derek

Patient Information:

Patient ID: 9988
Patient First Name: Derek
Patient Date of Birth: 11-01-2023
Gender: male
Assigned Office: NB1 east side
Primary Care Physician: Jose, Flores
Patient Status: Active

Primary Attendance / Assigned Therapists:

ST - Speech Therapy: Escobar, Stephanie
FD - Feeding Therapy:
OT - Occupational Therapy:
PT - Physical Therapy:

Patient Primary Authorizations:

Auth. IDStatusStart DateEnd DateInsuranceST-UnitsFD-UnitsOT-UnitsPT-Units
23683Active03-30-202609-25-2026Tricare Prime52000

Speech and Language Evaluation:

IDDateTypeEvaluation Diagnosis
2639603-02-2026Speech Initial EvaluationF80.2
Speech Background History: Derek is a 2-year-old male who was reported to be born full term with no complications during pregnancy or delivery and did not require a NICU stay. No significant medical illnesses, hospitalizations, or accidents have been reported to date. Developmentally, Derek reportedly met early gross motor milestones such as crawling and walking within expected timeframes. However, caregiver report indicates delays in expressive language development, as Derek currently uses approximately 20 words and attempts to communicate verbally but is not consistently understood. Sleep was reported to be generally adequate, with Derek obtaining approximately 8–10 hours of sleep per night, though caregiver reports he may occasionally wake during the night. Mild snoring was reported. Derek is currently taking antibiotics due to ear infection. Derek currently remains at home with his mother and siblings and is not enrolled in school or daycare at this time. No concerns regarding vision, hearing, feeding, or swallowing were reported. Caregiver indicated that Derek interacts well with family members and siblings. Primary parental concerns at this time relate to speech and language development, particularly limited expressive vocabulary and reduced speech intelligibility.
Speech Medical History:
Speech Medications:
Speech Behavioral Observations: Attending Skills: Distractible, Response Rate: Mild 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: Interactive, Responds to greetings,
Speech Communication Weaknesses: Difficult to understand, Diminished vocabulary, Poor vocabulary,
Speech Background Summary:
Speech Diagnosis/Impressions: Based on standardized testing, clinical observation, and parent report, Derek presents with a severe mixed receptive-expressive language disorder characterized by significant delays in understanding language, following directions, identifying familiar objects, and using functional expressive language to communicate wants and needs. Derek demonstrates emerging communication skills; however, his expressive vocabulary remains limited to approximately 20–25 words, and he is not yet combining words into phrases, which is expected for children his age. Additionally, Derek’s speech intelligibility is significantly reduced, making it difficult for unfamiliar listeners to understand his verbal attempts. During the evaluation, Derek demonstrated difficulty attending to structured tasks, following verbal directions without repetition, and identifying familiar objects within pictures or groups, further indicating delays in receptive language development. These communication deficits significantly impact Derek’s ability to effectively communicate his basic wants and needs, follow directions, participate in daily routines, and engage in age-appropriate social interactions with others. Parent report indicates that Derek frequently requires multiple repetitions of directions before responding, and his limited expressive vocabulary often results in reliance on gestures, vocalizations, or repetition of language heard in his environment rather than functional communication. Given the severity of Derek’s receptive and expressive language delays, skilled speech-language therapy is medically necessary in order to facilitate the development of foundational communication skills. Without intervention, Derek is at risk for continued communication breakdowns, increased frustration, reduced participation in social interactions, and delays in overall cognitive, social, and academic development. Speech-language therapy will target receptive language comprehension, expressive vocabulary expansion, early word combinations, and functional communication skills in order to improve Derek’s ability to communicate effectively across environments including the home, community, and future educational settings.
Speech Diagnosis/Impressions: Based on standardized testing, clinical observation, and parent report, Derek presents with a severe mixed receptive-expressive language disorder characterized by significant delays in understanding language, following directions, identifying familiar objects, and using functional expressive language to communicate wants and needs. Derek demonstrates emerging communication skills; however, his expressive vocabulary remains limited to approximately 20–25 words, and he is not yet combining words into phrases, which is expected for children his age. Additionally, Derek’s speech intelligibility is significantly reduced, making it difficult for unfamiliar listeners to understand his verbal attempts. During the evaluation, Derek demonstrated difficulty attending to structured tasks, following verbal directions without repetition, and identifying familiar objects within pictures or groups, further indicating delays in receptive language development. These communication deficits significantly impact Derek’s ability to effectively communicate his basic wants and needs, follow directions, participate in daily routines, and engage in age-appropriate social interactions with others. Parent report indicates that Derek frequently requires multiple repetitions of directions before responding, and his limited expressive vocabulary often results in reliance on gestures, vocalizations, or repetition of language heard in his environment rather than functional communication. Given the severity of Derek’s receptive and expressive language delays, skilled speech-language therapy is medically necessary in order to facilitate the development of foundational communication skills. Without intervention, Derek is at risk for continued communication breakdowns, increased frustration, reduced participation in social interactions, and delays in overall cognitive, social, and academic development. Speech-language therapy will target receptive language comprehension, expressive vocabulary expansion, early word combinations, and functional communication skills in order to improve Derek’s ability to communicate effectively across environments including the home, community, and future educational settings.
Speech Recommendations: Speech Therapy: 2 time(s) a Week for 30 to 45 minute sessions

Speech and Language Plan of Care:

IDPlan of Care
58778
Plan Date: 03-02-2026
Speech Assessment Summary: Based on standardized testing, clinical observation, and parent report, Derek presents with a severe mixed receptive-expressive language disorder characterized by significant delays in understanding language, following directions, identifying familiar objects, and using functional expressive language to communicate wants and needs. Derek demonstrates emerging communication skills; however, his expressive vocabulary remains limited to approximately 20–25 words, and he is not yet combining words into phrases, which is expected for children his age. Additionally, Derek’s speech intelligibility is significantly reduced, making it difficult for unfamiliar listeners to understand his verbal attempts. During the evaluation, Derek demonstrated difficulty attending to structured tasks, following verbal directions without repetition, and identifying familiar objects within pictures or groups, further indicating delays in receptive language development. These communication deficits significantly impact Derek’s ability to effectively communicate his basic wants and needs, follow directions, participate in daily routines, and engage in age-appropriate social interactions with others. Parent report indicates that Derek frequently requires multiple repetitions of directions before responding, and his limited expressive vocabulary often results in reliance on gestures, vocalizations, or repetition of language heard in his environment rather than functional communication. Given the severity of Derek’s receptive and expressive language delays, skilled speech-language therapy is medically necessary in order to facilitate the development of foundational communication skills. Without intervention, Derek is at risk for continued communication breakdowns, increased frustration, reduced participation in social interactions, and delays in overall cognitive, social, and academic development. Speech-language therapy will target receptive language comprehension, expressive vocabulary expansion, early word combinations, and functional communication skills in order to improve Derek’s ability to communicate effectively across environments including the home, community, and future educational settings.
Speech Rehabilitation Potential: Good. with consistent Speech Therapy and parental support
Speech and Language Long Term Goals:
CategoryGoal Description
Home Management Intervention ProgramWhen 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.
Expressive LanguageIn one year’s time, Derek will increase speech intelligibility by using 1-2+ word utterances with familiar and unfamiliar listeners in familiar settings to communicate a variety of pragmatic functions with 90% accuracy in 4/5 consecutive sessions.
Receptive LanguageIn one year’s time, Derek will engage with peers and family and follow simple directions in familiar settings to communicate a variety of pragmatic functions with 90% accuracy in 4/5 consecutive sessions for the purpose of having meaningful communication and for his safety to be able to have his wants and needs understood by family, friends, peers and caregivers.
Speech and Language Short Term Goals:
CategoryGoal Description
Receptive LanguageIn 6 months, Derek will follow simple directions incorporating basic language concepts and core vocabulary (open, close, stop, go, sit, give, etc) with 60% accuracy across 3 sessions when given min-no cues or the purpose understanding and improving functionally communicating with his family, friends and caregivers.
Receptive Language In 6 months Derek will increase vocabulary skills by identifying/using early concepts(i.e body parts. colors, etc.) with minimal to no cues at 60% accuracy across 3 consecutive sessions to assist with decreasing frustration and tantrum outburst
Play/SocializationIn 6 months Derek will appropriately engage and turn take with therapist/play partner with 70% accuracy with minimal to no cueing, across 3 consecutive sessions to increase socialization skills with familiar and unfamiliar people
Expressive LanguageIn 6 months time Derek will label common objects with 60% accuracy and minimal cues, across 3 consecutive sessions to assist with expressive language skills.
Expressive LanguageIn 6 months, Derek will imitate/produce 1-2 word utterances via total communication (gestures, signs, verbal expression, AAC, etc.,) during activity with 60% accuracy, with minimal to no cues across 3 consecutive sessions to assist with requesting wants/needs
Expressive LanguageWithin 6 months, Derek will produce early developing consonant-vowel (CV) or consonant-vowel-consonant-vowel (CVCV) word structures (e.g., mama, baba, cookie approximations) with 60% accuracy across three consecutive sessions

Completed Appointments:

IDPlan of Care
Appt-IDServiceStart-DateEnd-DateTherapistLocationStatus
89968792523: Artic & Language Eval03-02-2026 02:00 PM03-02-2026 03:00 PMStephanie EscobarNB1 east sideCompleted

Paient Notes:

DatePosted ByDescription
03-27-2026Shekinah VelasquezST auth approved starting 03/30/2026 - 09/25/2026 2x/ week = 52 visits. Therapist notified

Paient Messages Admin:

DatePosted ByMessage
02-23-2026 09:29 AMJulie MoraPlease fillout the form https://patient.newbeginnings-elp.com/Registration/default.aspx?sid=2665
02-23-2026 09:43 AMShekinah VelasquezDerek has been added to our Speech & Language Therapy wait list. To send us a message at any time, just respond here. To check the status of the wait list, click this link https://patient.newbeginnings-elp.com/Schedule/waitlist_status.aspx?pid=9988&type=1&wid=602
03-09-2026 07:22 PMStephen TulliusPlease join us for the next New Beginnings free Parent Training: Sensory Play. In this session learn how to create safe, engaging sensory experiences that help hypersensitive children regulate their responses to touch, sound, and movement. Register here: https://patient.newbeginnings-elp.com/trainings/default.aspx?id=20&pid=9988
03-11-2026 05:40 PMStephen TulliusHello, for anybody who would like to attend our Sensory Play parent training today but can't, we will be attempting a webinar version. You can register to see it online at https://webinar.getresponse.com/JvvC9/sensory-play/
03-23-2026 11:31 AMShekinah VelasquezHello Tricare Families,

We would like to inform you of an important update regarding therapy services. Due to a recent change in Tricare’s process, all patients are now required to be seen by their Primary Care Provider (PCP/PCM) and have an updated referral submitted to Tricare before we can request authorization for therapy.

Please note:
-The referral end date provided by your PCP/PCM will determine the authorization period for therapy services.
-If possible, we recommend requesting a referral period of up to one year, as this will help reduce the number of required follow-up visits.
-If you are unsure whether a current referral is on file, please contact your PCP/PCM or Tricare Referral Management directly.

This change began earlier this month. While we are actively reviewing all existing referrals, we kindly ask for your assistance in scheduling an appointment with your PCP/PCM and ensuring an updated referral is submitted to help avoid any delays in therapy services.

If you are able to view your referral end date, please be aware that your child will need to be seen again before that date to continue services.

We appreciate your patience and cooperation during this transition. If you have any questions, please don’t hesitate to contact our office.

Thank you for your time and support.
03-27-2026 06:27 PMShekinah VelasquezHi, Derek as been assigned a therapist for Speech and Language therapy. Here's a link to learn more about Stephanie https://st-pros.com/newbeginnings/reports/welcomefromtherapist.aspx?id=9988&tid=125

Paient Messages Therapist:

DatePosted ByMessage
03-01-2026 06:30 PMStephanie EscobarHola, esto es solo un recordatorio de que Derek tiene una cita programada para una evaluación de terapia de habla y lenguaje manana a las 02:00 PM. Nos vemos pronto! - New Beginnings 🙂
03-02-2026 07:58 AMStephanie EscobarHola, esto es solo un recordatorio de que Derek tiene una cita programada para una evaluación de terapia de habla y lenguaje hoy a las 02:00 PM. Nos vemos pronto! - New Beginnings 🙂
03-02-2026 01:45 PMStephanie EscobarDerek FloresOrtiz-Rodriguez : Time to check in at New Beginnings 🙂 Click here https://patient.newbeginnings-elp.com/checkin/default.aspx?AppId=899687
03-02-2026 01:58 PMDerek FloresOrtiz-RodriguezDerek is CHECKED IN for:
2:00PM-3/2/2026
92523: Artic & Language Eval