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This document serves as a request form for speech/language evaluations or therapy at the Eardley Family Clinic for Speech, Language and Hearing, including necessary case history and payment information.

How to fill out speechlanguage evaluation and therapy

How to fill out Speech/Language Evaluation and Therapy Request Form

1. Begin by entering the patient's personal information at the top of the form.
2. Fill in the reason for the evaluation or request for therapy in the designated section.
3. Provide detailed information about the patient's medical history relevant to speech and language.
4. Include any specific concerns noted by parents, caregivers, or teachers.
5. Complete the section about previous evaluations or treatments received.
6. Indicate preferred therapy goals or outcomes based on the patient's needs.
7. Sign and date the form, and ensure all required fields are completed.

Who needs Speech/Language Evaluation and Therapy Request Form?

1. Individuals showing signs of speech or language difficulties.
2. Children with developmental delays affecting communication.
3. Patients recovering from a stroke or brain injury impacting speech.
4. Anyone needing a formal assessment for therapy services.

For pdfFiller’s FAQs

What is Speech/Language Evaluation and Therapy Request Form?

The Speech/Language Evaluation and Therapy Request Form is a document used to initiate an assessment and potential treatment for individuals experiencing speech and language difficulties.

Who is required to file Speech/Language Evaluation and Therapy Request Form?

Typically, it is required to be filed by parents, guardians, or healthcare professionals who identify a child's or individual's need for speech and language evaluation and therapy.

How to fill out Speech/Language Evaluation and Therapy Request Form?

To fill out the form, provide accurate personal information, ensure all required sections are completed, describe the communication concerns, and any previous interventions before submitting it to the appropriate services.

What is the purpose of Speech/Language Evaluation and Therapy Request Form?

The purpose of the form is to formally request a speech/language evaluation which can lead to diagnosis and treatment options for speech and language disorders.

What information must be reported on Speech/Language Evaluation and Therapy Request Form?

Essential information includes the individual's personal details, specific speech or language concerns, previous assessment results, and any relevant medical history.