| ID | Date | Type | Evaluation Diagnosis |
26285 | 02-17-2026 | Speech Initial Evaluation | F80.2 | | Speech Background History: Sebastian is a 1 year-old and 9 month-old male who was referred for a speech and language evaluation by his pediatrician due to language delay. Mrs. Pimentel accompanied him and served as the primary informant for the evaluation. Mrs. Pimentel expressed concern that Sebastian primarily communicates using limited words, vocalizations, and gestures to express his needs and wants. During the evaluation, Sebastian’s expressive language was characterized primarily by symbolic gestures (pointing) and some vocalizations. According to developmental norms, a typically developing child of Sebastian’s age should have an expressive vocabulary of approximately 10-50 words. Sebastian was evaluated using the Preschool Language Scales Fifth Edition (PLS-5) Dual Language Assessment. LANGUAGE BACKGROUND: LANGUAGE INPUT: Sebastian’s mother reported that he is exposed to English and Spanish within his home environment. LANGUAGE OUTPUT: During the evaluation, Sebastian did not have any verbal output. LANGUAGE OF INTERVENTION: It is recommended that intervention be conducted primarily in English and Spanish as needed. |
| Speech Medical History: According to the parent report, Sebastian was born without any complications prior to, during, or following the delivery. |
| Speech Medications: None |
| Speech Behavioral Observations: Attending Skills: Inconsistent, Response Rate: Moderate delays, Level of Activity: Passive, Cooperation: Passive, 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: Appropriate use of eye contact, |
| Speech Communication Weaknesses: Poor vocabulary, |
| Speech Background Summary: Sebastian was accompanied to the evaluation by his mother, and the assessment was conducted in a clinic room setting. Throughout the evaluation, Sebastian required FREQUENT and NUMEROUS prompts to engage in assessment tasks. He presented as SHY and QUIET, preferring to remain in close proximity to his mother and often sitting on her lap. His mother reported that he does not interact with unfamiliar individuals. Additionally, she stated that when Sebastian becomes frustrated or angry, he may throw himself to the floor and/or throw objects. |
| Speech Diagnosis/Impressions: Sebastian is a 1 year-old and 9 month-old male who was referred for a speech and language evaluation by his pediatrician due to language delay. Mrs. Pimentel accompanied him and served as the primary informant for the evaluation. Mrs. Pimentel expressed concern that Sebastian primarily communicates using limited words, vocalizations, and gestures to express his needs and wants. During the evaluation, Sebastian’s expressive language was characterized primarily by symbolic gestures (pointing) and some vocalizations. According to developmental norms, a typically developing child of Sebastian’s age should have an expressive vocabulary of approximately 10-50 words. LANGUAGE BACKGROUND: LANGUAGE INPUT: Sebastian’s mother reported that he is exposed to English and Spanish within his home environment. During the evaluation, Sebastian did not produce any verbal output. LANGUAGE OF INTERVENTION: It is recommended that intervention be conducted in English and Spanish, with support as needed. During the evaluation, Sebastian required FREQUENT and NUMEROUS prompts to engage in assessment tasks. He presented as SHY and QUIET, preferring to remain in close proximity to his mother and often sitting on her lap. His mother reported that he does not interact with unfamiliar individuals. Additionally, she stated that when Sebastian becomes frustrated or angry, he may throw himself to the floor and/or throw objects. Sebastian was evaluated using the Preschool Language Scales Fifth Edition (PLS-5) Dual Language Assessment. Sebastian received the following Standard Scores on the PLS-5: Auditory Comprehension 78 (raw score: 18, percentile: 7, age equivalent:1 year 2 months), Expressive Communication 74 (raw score: 17, percentile: 4, age equivalent: 1 year 0 months, and Total Language Score 74 (percentile: 4, age equivalent: 1 year 1 months). According to the Standard Scores that Sebastian received, he presents with MODERATE 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 Sebastian’s MODERATE MIXED RECEPTIVE-EXPRESSIVE LANGUAGE DISORDER. Sebastian would greatly benefit from speech therapy that targets the following age-appropriate concepts: joint attention/sustaining attention to tasks, demonstrating functional play, identifying common objects, following 1-step directions, imitating non-speech and environmental sounds, and one- to two-syllable words. Speech therapy is highly recommended at this time as Sebastian's current speech and language skills are NOT DEVELOPMENTALLY FUNCTIONAL for his age. Without speech therapy, Sebastian’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. Sebastian’s mother will be responsible for his Home Exercise Program (HEP).
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| Speech Diagnosis/Impressions: Sebastian is a 1 year-old and 9 month-old male who was referred for a speech and language evaluation by his pediatrician due to language delay. Mrs. Pimentel accompanied him and served as the primary informant for the evaluation. Mrs. Pimentel expressed concern that Sebastian primarily communicates using limited words, vocalizations, and gestures to express his needs and wants. During the evaluation, Sebastian’s expressive language was characterized primarily by symbolic gestures (pointing) and some vocalizations. According to developmental norms, a typically developing child of Sebastian’s age should have an expressive vocabulary of approximately 10-50 words. LANGUAGE BACKGROUND: LANGUAGE INPUT: Sebastian’s mother reported that he is exposed to English and Spanish within his home environment. During the evaluation, Sebastian did not produce any verbal output. LANGUAGE OF INTERVENTION: It is recommended that intervention be conducted in English and Spanish, with support as needed. During the evaluation, Sebastian required FREQUENT and NUMEROUS prompts to engage in assessment tasks. He presented as SHY and QUIET, preferring to remain in close proximity to his mother and often sitting on her lap. His mother reported that he does not interact with unfamiliar individuals. Additionally, she stated that when Sebastian becomes frustrated or angry, he may throw himself to the floor and/or throw objects. Sebastian was evaluated using the Preschool Language Scales Fifth Edition (PLS-5) Dual Language Assessment. Sebastian received the following Standard Scores on the PLS-5: Auditory Comprehension 78 (raw score: 18, percentile: 7, age equivalent:1 year 2 months), Expressive Communication 74 (raw score: 17, percentile: 4, age equivalent: 1 year 0 months, and Total Language Score 74 (percentile: 4, age equivalent: 1 year 1 months). According to the Standard Scores that Sebastian received, he presents with MODERATE 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 Sebastian’s MODERATE MIXED RECEPTIVE-EXPRESSIVE LANGUAGE DISORDER. Sebastian would greatly benefit from speech therapy that targets the following age-appropriate concepts: joint attention/sustaining attention to tasks, demonstrating functional play, identifying common objects, following 1-step directions, imitating non-speech and environmental sounds, and one- to two-syllable words. Speech therapy is highly recommended at this time as Sebastian's current speech and language skills are NOT DEVELOPMENTALLY FUNCTIONAL for his age. Without speech therapy, Sebastian’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. Sebastian’s mother will be responsible for his Home Exercise Program (HEP).
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| Speech Recommendations: Speech Therapy: 1 time(s) a Week for 45 to 60 minute sessions |
| ID | Plan of Care |
| 58447 | | Plan Date: 02-17-2026 | | Speech Assessment Summary: Sebastian is a 1 year-old and 9 month-old male who was referred for a speech and language evaluation by his pediatrician due to language delay. Mrs. Pimentel accompanied him and served as the primary informant for the evaluation. Mrs. Pimentel expressed concern that Sebastian primarily communicates using limited words, vocalizations, and gestures to express his needs and wants. During the evaluation, Sebastian’s expressive language was characterized primarily by symbolic gestures (pointing) and some vocalizations. According to developmental norms, a typically developing child of Sebastian’s age should have an expressive vocabulary of approximately 10-50 words. LANGUAGE BACKGROUND: LANGUAGE INPUT: Sebastian’s mother reported that he is exposed to English and Spanish within his home environment. During the evaluation, Sebastian did not produce any verbal output. LANGUAGE OF INTERVENTION: It is recommended that intervention be conducted in English and Spanish, with support as needed. During the evaluation, Sebastian required FREQUENT and NUMEROUS prompts to engage in assessment tasks. He presented as SHY and QUIET, preferring to remain in close proximity to his mother and often sitting on her lap. His mother reported that he does not interact with unfamiliar individuals. Additionally, she stated that when Sebastian becomes frustrated or angry, he may throw himself to the floor and/or throw objects. Sebastian was evaluated using the Preschool Language Scales Fifth Edition (PLS-5) Dual Language Assessment. Sebastian received the following Standard Scores on the PLS-5: Auditory Comprehension 78 (raw score: 18, percentile: 7, age equivalent:1 year 2 months), Expressive Communication 74 (raw score: 17, percentile: 4, age equivalent: 1 year 0 months, and Total Language Score 74 (percentile: 4, age equivalent: 1 year 1 months). According to the Standard Scores that Sebastian received, he presents with MODERATE 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 Sebastian’s MODERATE MIXED RECEPTIVE-EXPRESSIVE LANGUAGE DISORDER. Sebastian would greatly benefit from speech therapy that targets the following age-appropriate concepts: joint attention/sustaining attention to tasks, demonstrating functional play, identifying common objects, following 1-step directions, imitating non-speech and environmental sounds, and one- to two-syllable words. Speech therapy is highly recommended at this time as Sebastian's current speech and language skills are NOT DEVELOPMENTALLY FUNCTIONAL for his age. Without speech therapy, Sebastian’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. Sebastian’s mother will be responsible for his Home Exercise Program (HEP).
| | Speech Rehabilitation Potential: Good. with consistent Speech Therapy and parental support. Sebastian 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 that 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, Sebastian will improve his expressive language skills with 50% accuracy across 5 consecutive sessions in order to improve his verbal output to effectively communicate pain (i.e. tell his mom if stomach hurts) and safety issues (i.e. express when someone hits or bites him at school) with familiar listeners in familiar settings. | | Receptive Language | In 12 months, Sebastian will improve his receptive language skills with 50% accuracy across 5 consecutive sessions in order to improve his auditory comprehension to effectively understand information in his day to day situations. |
| | Speech and Language Short Term Goals: | | Category | Goal Description | | Expressive Language | In 6 months, Sebastian will imitate non-speech /environmental sounds modeled by clinician by clinician by clinician in 3 out of 10 opportunities across 3 consecutive sessions in order to improve adequate sentence structure of his functional communication. | | Expressive Language | In 6 months, Sebastian will imitate actions/gestures modeled by clinician by clinician by clinician in 3 out of 10 opportunities across 3 consecutive sessions in order to improve adequate sentence structure of his functional communication. | | Receptive Language | In 6 months, Sebastian will identify common objects by pointing or grabbing with 30% accuracy across 3/5 consecutive session in order to comprehend instructions related to activities of daily living and safety situations (i.e., wash hands, cross the street). | | Play/Socialization | In 6 months, Sebastian will engage in functional play with 30% accuracy given fading cues across 3 consecutive sessions in order to promote opportunities for language growth | | Play/Socialization | In 6 months, Sebastian will demonstrate joint attention during play with 30% accuracy given fading cues across 3 consecutive sessions in order to promote opportunities for language growth. | | Receptive Language | In 6 months, Sebastian will follow everyday functional directions (e.g., sit down, give me, come here, throw the ball) with 30% accuracy given fading cues across 3 consecutive sessions in order to promote safety when following safety instructions. |
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