Note: In addition, it is important to note that the “date of referral” is the date the school district receives the informed written consent for the evaluation. This date begins the 60-school-day timeline during which the case study evaluation, Eligibility Determination Conference, Individualized Educational Program conference and placement determinations must be made. Note: If the parent waived 10-day notice, then check that box on the “Notification of Conference” form. If it is determined that an evaluation is not appropriate at this time, complete the “Parent/Guardian Notification of Decision Regarding A Request for an Evaluation.” On the bottom half of the page, mark the box for “evaluation is not appropriate at this time. Give to the following: Parent/Guardian Referring Agent SLP
Severe – 3 Service Delivery Units Minimum of 61-90 Minutes per week Profound – 5 Service Delivery Units Minimum of 91 + Minutes per Week SEVERITY OF DISORDER Impairment limits the individual’s ability to communicate appropriately and respond in school learning and/or social situations. Environmental and/or student concern is evident and documented. Impairment prevents the individual from communicating appropriately in school and/or social situations.
2-3 mo. □ reacts positively to human □ babbling, cooing, gurgling N/A N/A voice □ imitates adult sounds □ discriminates caregiver’s □ repeats sounds for physical voice pleasure 3-4 mo. □ cause/effect emerges □ smiles, laughs N/A N/A □ recognizes mother’s voice □ responds vocally/bodily to intonation changes □ uses suckling pattern if spoon is introduced □ responsive sound if spoken to □ initiates vocalizations by Babbling 101 Age Receptive Expressive Phonology Pragmatics 4-5 mo. □ turns head at sound of voice □ laughs, vowel sounds N/A N/A □ follows mother’s visual focus □ sucking pattern more □ recognizes stimuli that vary in frequent than suckling pattern □ localizes sounds □ laughs aloud in response N/A N/A to others □ self-initiates sound play □ prelinguistic vocalization (vowels, raspberries) 5-6 mo. □ recognizes familiar melodies □ solitary vocal play N/A N/A □ coos, babbles, high squeal □ indicates needs by crying □ @ angry voice □ laughs @ pleasant voice
6-7 mo. □ listens to own □ several well defined syllables N/A N/A □ knows when to smile □ VC syllables □ imitates specific sounds □ vocalizes to music □ signals end of turn by gaze □ directs sounds & gestures to objects (ASHA) – “How Does Your Hear and Talk?”; ( Hospital Speech-Language Therapy) “Developmental Continuity Clinic Evaluation Report”; (Caroline Bowen Ph.D. SLP) “Ages & Stages Developmental Milestones”; (Child Development Institute) “Language Development In Children” 102 Age Receptive Expressive Phonology Pragmatics 7-8 mo □ understands 1st words (no-no) □ Pays attn. to family □ vowel sounds in a series N/A N/A member voices □ vocalizes satisfaction re: object □ attend to pictures □ vocalizes emotional state □ searches for hidden objects □ reaches for self in mirror □ recognizes name □ deep sounds/grunts 8-9 mo. □ alert to environmental □ vocalizes to familiar items N/A N/A stimuli □ shouts/vocalizes to gain attn. □ explores toys orally □ vocalizes 2 syllable combinations (reduplicated or varigated)
24-36 mo. □ understands concept of “I” □ MLU 3 words □ emerging k,g □ emerging proximity □ understands function of □ uses negation (no, not, d, ng, f rules objects don’t) □ produces final □ demonstrates □ understands simple uses regular plurals consonants parallel play, □ understands prepositional □ uses possessive markers emerging inter- phrases □ uses present tense (-ing, -s) active play □ understands prepositions □ repeats 2 unrelated (on, in, under) □ states 1st & last name □ understands subjective □ asks & answers yes/no pronouns (he, she, it) questions □ answers “who”, “what”, “where” questions 104 Age Receptive Expressive Phonology Pragmatics 36-48mo. □ understands prepositions □ MLU: 3 to 4 words □ emerging r, L. □ exhibits proximity (over, behind) □ names 4 colors s, y rules, □ groups objects into categories □ tells about immediate □ consonant □ initiates context (toys, animals, clothes, experiences blends emerging relevant topics food) □ states function of objects □ states feelings & □ provides logical answers to needs questions (i.e. what do you □ interactive play do when you’re sleepy?) □ recognizes distress □ answers “when” questions of a peer □ completes simple analogies □ refers to self with name, age, gender
Response to thickened liquids__________________________________________________________________________ Recommendations___________________________________________________________________________________ SWALLOWING CONCERNS: □ pneumonia or history of pneumonia □ gagging □ delayed swallow □ coughing □ multiple swallows □ wet voice □ chronic low grade fever □ congestion □ chronic, copious, clear secretions □ concerns related to weight □ oral cavity not clear after swallow □ tongue pumping □ larynx does not elevate properly RESPONSE TO FEEDING: □ alert throughout □ lethargic □ irritable □ facial grimacing □ anxious □ irregular or audible breathing □ refusal □ vomiting □ increased hypertonicity □ reflux □ fatigue □ facial reddening Other________________________________________________________________________ ________________________________________ ________________________________________________ Completed Completed by/Title D21 Feeding and Swallowing Evaluation Positioning for Feeding: Checklist: ____ Body symmetrical ____ Head upright ____ Arms supported ____ Pelvis anchored and squared ____ Hips flexed at 90 degrees ____ Thighs separated