| ID | Date | Type | Evaluation Diagnosis |
26378 | 03-06-2026 | Speech Initial Evaluation | F80.2 | | Speech Background History: Robert is a 2-year-old and 7-month-old male who was referred for a speech and language evaluation by his pediatrician due to language delay. Mrs. Terrazas accompanied him and served as the primary informant for the evaluation. Mrs. Terrazas expressed concerns that Robert primarily communicates through vocalizations and word approximations and relies heavily on gestures, such as pointing, to express his wants and needs. During the evaluation, Robert’s expressive language was characterized primarily by vocalizations and symbolic gestures (pointing). According to developmental norms, a typically developing child of Robert’s age should have an expressive vocabulary of approximately 300 words and produce 2-word utterances. Robert was evaluated using the Preschool Language Scales Fifth Edition (PLS-5). LANGUAGE BACKGROUND: LANGUAGE INPUT: Robert’s mother reported that he is exposed to English within his home environment. LANGUAGE OUTPUT: During the evaluation, Robert produced minimal verbal output. LANGUAGE OF INTERVENTION: It is recommended that intervention be conducted in English.
|
| Speech Medical History: Mrs. Terrazas reported experiencing gestational diabetes and high blood pressure during pregnancy. Following birth, Robert’s lungs were not functioning appropriately, and he required care in the NICU for approximately one week. She also reported that Robert has seasonal allergies. |
| Speech Medications: None |
| Speech Behavioral Observations: Attending Skills: Distractible, Response Rate: Mild delays, Level of Activity: WNL, Cooperation: WNL, Communicative Intent: With numerous prompts, Awareness of Others: Present, Reliability of Scores: Adequate, Awarencess of Environmental Events: Good, Social Interactions: Usually, Prognosis for Improved Communicative Functioning: Shy, |
| Speech Communication Strengths: |
| Speech Communication Weaknesses: Unable to follow commands, Use of jargon, |
| Speech Background Summary: Robert's mother accompanied him to the evaluation, which took place in the clinic room. Throughout the evaluation, Robert displayed signs of distractibility, as evidenced by his difficulty in remaining seated and his need for FREQUENT and NUMEROUS prompts to participate in the evaluation process. |
| Speech Diagnosis/Impressions: Robert is a 2-year-old and 7-month-old male who was referred for a speech and language evaluation by his pediatrician due to language delay. Mrs. Terrazas accompanied him and served as the primary informant for the evaluation. Mrs. Terrazas expressed concerns that Robert primarily communicates through vocalizations and word approximations and relies heavily on gestures, such as pointing, to express his wants and needs. During the evaluation, Robert’s expressive language was characterized primarily by vocalizations and symbolic gestures (pointing). According to developmental norms, a typically developing child of Robert’s age should have an expressive vocabulary of approximately 300 words and produce 2-word utterances. LANGUAGE BACKGROUND: LANGUAGE INPUT: Robert’s mother reported that he is exposed to English within his home environment. LANGUAGE OUTPUT: During the evaluation, Robert produced minimal verbal output. LANGUAGE OF INTERVENTION: It is recommended that intervention be conducted in English. Throughout the evaluation, Robert displayed signs of distractibility, as evidenced by his difficulty staying seated and his need for FREQUENT and NUMEROUS prompts to participate. Robert was evaluated using the Preschool Language Scales Fifth Edition (PLS-5). Robert received the following Standard Scores on the PLS-5: Auditory Comprehension 67 (raw score: 23, percentile: 1, age equivalent:1 year 3 months), Expressive Communication 68 (raw score: 21, percentile: 2, age equivalent: 1 year 3 months), and Total Language Score 65 (percentile: 1, age equivalent: 1 year 6 months). According to the Standard Scores that Robert received, he presents with SEVERE MIXED RECEPTIVE -EXPRESSIVE LANGUAGE DISORDER.
RECOMMENDATIONS: At this time, speech and language therapy at the rate of 1x per week for 45-60 minutes is warranted to treat Robert’s SEVERE MIXED RECEPTIVE/EXPRESSIVE LANGUAGE DISORDER. Robert would greatly benefit from speech therapy that targets the following ageappropriate concepts: joint attention/sustaining attention to tasks, demonstrating appropriate play skills, following directions using common objects, imitating environmental/non-speech sounds, imitating words, and tolerating "no" or "wait" without adverse behaviors. Speech therapy is highly recommended at this time as Robert’s current speech and language skills are NOT DEVELOPMENTALLY FUNCTIONAL for his age. Without speech therapy, Robert’s safety risk is high since he will not likely be understood if he needs to communicate pain, communicate need for assistance, or understand safety personnel/directions. Robert’s mother will be responsible for his Home Exercise Program (HEP) to promote skill progress and generalization.
|
| Speech Diagnosis/Impressions: Robert is a 2-year-old and 7-month-old male who was referred for a speech and language evaluation by his pediatrician due to language delay. Mrs. Terrazas accompanied him and served as the primary informant for the evaluation. Mrs. Terrazas expressed concerns that Robert primarily communicates through vocalizations and word approximations and relies heavily on gestures, such as pointing, to express his wants and needs. During the evaluation, Robert’s expressive language was characterized primarily by vocalizations and symbolic gestures (pointing). According to developmental norms, a typically developing child of Robert’s age should have an expressive vocabulary of approximately 300 words and produce 2-word utterances. LANGUAGE BACKGROUND: LANGUAGE INPUT: Robert’s mother reported that he is exposed to English within his home environment. LANGUAGE OUTPUT: During the evaluation, Robert produced minimal verbal output. LANGUAGE OF INTERVENTION: It is recommended that intervention be conducted in English. Throughout the evaluation, Robert displayed signs of distractibility, as evidenced by his difficulty staying seated and his need for FREQUENT and NUMEROUS prompts to participate. Robert was evaluated using the Preschool Language Scales Fifth Edition (PLS-5). Robert received the following Standard Scores on the PLS-5: Auditory Comprehension 67 (raw score: 23, percentile: 1, age equivalent:1 year 3 months), Expressive Communication 68 (raw score: 21, percentile: 2, age equivalent: 1 year 3 months), and Total Language Score 65 (percentile: 1, age equivalent: 1 year 6 months). According to the Standard Scores that Robert received, he presents with SEVERE MIXED RECEPTIVE -EXPRESSIVE LANGUAGE DISORDER.
RECOMMENDATIONS: At this time, speech and language therapy at the rate of 1x per week for 45-60 minutes is warranted to treat Robert’s SEVERE MIXED RECEPTIVE/EXPRESSIVE LANGUAGE DISORDER. Robert would greatly benefit from speech therapy that targets the following ageappropriate concepts: joint attention/sustaining attention to tasks, demonstrating appropriate play skills, following directions using common objects, imitating environmental/non-speech sounds, imitating words, and tolerating "no" or "wait" without adverse behaviors. Speech therapy is highly recommended at this time as Robert’s current speech and language skills are NOT DEVELOPMENTALLY FUNCTIONAL for his age. Without speech therapy, Robert’s safety risk is high since he will not likely be understood if he needs to communicate pain, communicate need for assistance, or understand safety personnel/directions. Robert’s mother will be responsible for his Home Exercise Program (HEP) to promote skill progress and generalization.
|
| Speech Recommendations: Speech Therapy: 1 time(s) a Week for 45 to 60 minute sessions |
| ID | Plan of Care |
| 58729 | | Plan Date: 03-06-2026 | | Speech Assessment Summary: Robert is a 2-year-old and 7-month-old male who was referred for a speech and language evaluation by his pediatrician due to language delay. Mrs. Terrazas accompanied him and served as the primary informant for the evaluation. Mrs. Terrazas expressed concerns that Robert primarily communicates through vocalizations and word approximations and relies heavily on gestures, such as pointing, to express his wants and needs. During the evaluation, Robert’s expressive language was characterized primarily by vocalizations and symbolic gestures (pointing). According to developmental norms, a typically developing child of Robert’s age should have an expressive vocabulary of approximately 300 words and produce 2-word utterances. LANGUAGE BACKGROUND: LANGUAGE INPUT: Robert’s mother reported that he is exposed to English within his home environment. LANGUAGE OUTPUT: During the evaluation, Robert produced minimal verbal output. LANGUAGE OF INTERVENTION: It is recommended that intervention be conducted in English. Throughout the evaluation, Robert displayed signs of distractibility, as evidenced by his difficulty staying seated and his need for FREQUENT and NUMEROUS prompts to participate. Robert was evaluated using the Preschool Language Scales Fifth Edition (PLS-5). Robert received the following Standard Scores on the PLS-5: Auditory Comprehension 67 (raw score: 23, percentile: 1, age equivalent:1 year 3 months), Expressive Communication 68 (raw score: 21, percentile: 2, age equivalent: 1 year 3 months), and Total Language Score 65 (percentile: 1, age equivalent: 1 year 6 months). According to the Standard Scores that Robert received, he presents with SEVERE MIXED RECEPTIVE -EXPRESSIVE LANGUAGE DISORDER.
RECOMMENDATIONS: At this time, speech and language therapy at the rate of 1x per week for 45-60 minutes is warranted to treat Robert’s SEVERE MIXED RECEPTIVE/EXPRESSIVE LANGUAGE DISORDER. Robert would greatly benefit from speech therapy that targets the following ageappropriate concepts: joint attention/sustaining attention to tasks, demonstrating appropriate play skills, following directions using common objects, imitating environmental/non-speech sounds, imitating words, and tolerating "no" or "wait" without adverse behaviors. Speech therapy is highly recommended at this time as Robert’s current speech and language skills are NOT DEVELOPMENTALLY FUNCTIONAL for his age. Without speech therapy, Robert’s safety risk is high since he will not likely be understood if he needs to communicate pain, communicate need for assistance, or understand safety personnel/directions. Robert’s mother will be responsible for his Home Exercise Program (HEP) to promote skill progress and generalization.
| | Speech Rehabilitation Potential: Good. with consistent Speech Therapy and parental support. Robert will be discharged when he achieves a standard score above - 1.5 standard deviations from the mean for ALL impairments, indicating that his speech and language skills will be in the mild to average range and he will have met all long term therapy goals. | | 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. | | Expressive Language | In 12 months, Robert will improve his expressive language skills with 80% accuracy across 5 consecutive sessions in order to effectively communicate pain (i.e. tell his mom if stomach hurts) and safety issues (i.e. express when someone hits or bites his at school) with familiar listeners in familiar settings. | | Receptive Language | In 12 months, Robert will improve his receptive language skills with 80% accuracy across 5 consecutive sessions in order to follow safety concerns (i.e. follow safety personnel) and provide vital information to emergency personnel (i.e. name). |
| | Speech and Language Short Term Goals: | | Category | Goal Description | | Play/Socialization | In 6 months, Robert will sustain attention to therapy tasks with clinician for at least 1-2 minutes per task in 3 out of 10 opportunities across 3 consecutive sessions in order to promote language learning opportunities for language development. | | Play/Socialization | In 6 months, Robert will complete functional/relational play based tasks from beginning to end (i.e., completing a puzzle, stacking blocks, etc.) in 3 out of 10 opportunities across 3 consecutive sessions in order to promote language learning opportunities for language development. | | Expressive Language | In 6 months, Robert will imitate environmental/non-speech sounds modeled by clinician in 3 out of 10 opportunities across 3 consecutive sessions in order to improve use of meaningful language for functional communication in everyday activities (i.e stating what he wants to play, when he is sick). | | Expressive Language | In 6 months, Robert will imitate words modeled by clinician in 3 out of 10 opportunities across 3 consecutive sessions in order to improve use of meaningful language for functional communication in everyday activities (i.e stating what he wants to play, when he is sick). | | Receptive Language | In 6 months, Robert will follow 1 step instructions containing common objects in 3 out of 10 opportunities across 3 consecutive session in order to improve comprehension of instructions related to activities of daily living and safety situations (i.e. wash hands, cross the street). | | Play/Socialization | In 6 months, Robert will tolerate being told “no” or “wait”in 3 out of 10 opportunities WITHOUT ADVERSE BEHAVIORS across 3 consecutive sessions in order to improve social communication skills for functional language development. |
|
|