Speech Therapy Treatment Plan Form PDF Details

The Speech Therapy Treatment Plan form serves as a foundational bridge connecting patients who are in need of speech therapy services with their healthcare providers, ensuring a structured approach towards diagnosing and treating speech-related disorders. With sections neatly organized to capture essential information, this form begins by soliciting details about the patient's insurance and demographic specifics, such as name, age, and contact information, which are critical for identifying the patient and for billing purposes. The form meticulously outlines the patient's current medical history and the specific diagnosis necessitating speech therapy, underscoring the importance of a thorough understanding of the patient’s health status. It distinguishes between initial and continuing care, highlighting the plan's adaptability to the patient’s evolving needs. The treatment plan section delves into the patient's prior history with speech therapy, if any, and details regarding the onset of the primary diagnosis, facilitating a tailored therapy approach. Objective findings are structured to assess the severity and nature of the speech disorder, guiding therapists in setting realistic treatment goals and anticipated outcomes. Additionally, it requests information on the treatment's expected duration and frequency, enabling a structured timeline for therapy. Importantly, the form also emphasizes the involvement of additional diagnostic tools and prognostic indicators, like patient motivation and caregiver participation, suggesting a holistic approach to treatment planning. By requiring a healthcare provider's signature, the document underscores the accountability and professionalism expected in the treatment planning process, making it a crucial tool for both healthcare providers and patients embarking on a speech therapy journey.

QuestionAnswer
Form NameSpeech Therapy Treatment Plan Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesspeech treatment form, speech therapy treatment plan, speech therapy treatment plan sample, speech therapy treatment plan template

Form Preview Example

ST PAYOR INSURED

PATIENT’S CURRENT MEDICAL HISTORY

TREATMENT PLAN DIAGNOSES

Speech Therapy Treatment Plan

 

 

 

 

 

Date of this Request___/___/___

 

 

 

 

 

 

 

 

 

 

 

 

Landmark Healthcare, Inc.

 

 

 

 

 

 

 

Please check type of care:

 

 

 

 

 

 

 

 

 

 

 

 

FAX (888) 565-4225

 

 

 

 

 

 

 

 

 

 

Initial care

Continuing care

Patient Last Name

 

Patient First Name

 

M.I.

Gender

 

 

Age

 

Date of Birth (MM/DD/YYYY)

 

 

 

 

 

 

 

 

M

F

 

 

 

_____/_____/______

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Insured I.D. or SSN

 

Insured Last Name

 

M.I.

First Name

 

 

 

Patient Phone (area code first)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient Address

 

 

 

City

 

 

 

 

State

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer Name

 

Insurance Company

 

 

 

Group Plan # or Union Local (Submit Copy of Patient’s

 

 

 

 

 

 

 

 

Insurance I.D. Card)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Injury or illness is related to:

 

Referring Physician/Practitioner

 

Doctor License #

 

 

 

Date of Referral

Work

Auto Other

 

 

 

 

 

 

 

 

 

 

 

 

_____/_____/______

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Therapist Last Name

 

Therapist First Name

 

M.I.

 

Group Name

 

 

 

 

Provider/Group ID#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provider/Group Address

 

 

City

 

 

 

State

 

Zip Code

 

 

 

Phone # (

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fax # (

)

 

 

 

 

 

 

 

 

 

 

 

Previous Speech Therapy History

 

 

 

 

 

 

Mechanism of Onset for Primary Diagnosis

 

1st Visit ___/___/______

Discharge Date___/___/______

# of Visits _________ Date of Onset ___/___/______

Date of Initial Evaluation ___/___/______

 

 

 

 

 

 

 

 

Acute Onset

 

Developmental

 

Subjective Complaints:

 

 

 

 

 

 

Congenital

 

Neuro/CV/Cerebral Event

 

 

 

 

 

 

 

 

Chronic

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

Description:

 

 

 

 

 

 

(Circle one) Immediate pt. safety issue or Functional decline/improvement in ADLs

Objective Findings (note

Date obtained

 

 

Mild

Moderate

Severe

Current condition

 

 

 

 

any deficits)

 

____/____/______

 

Date of onset __/__/____

 

Date of initial evaluation __/__/____

Attention/orientation

 

 

 

 

 

 

 

New condition

 

 

□

 

Initiation/follow-through

 

 

 

 

 

 

 

Gradual onset

 

 

□

 

Problem solving/judgment

 

 

 

 

 

 

 

Behavioral change

 

 

□

 

Sequencing/organization

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Worsening of prior illness/trauma

 

□

 

Following directions

1-step

 

 

 

 

 

 

 

 

 

 

 

 

Trauma

 

 

□

 

 

 

 

2-step

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pt/family request

 

 

□

 

 

 

 

multi-step

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other

 

 

 

□

 

Verbal expression

word level

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

sentence level

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Conversational

 

 

 

 

 

Summary of Clinical Findings

 

 

 

 

 

 

basic needs

 

 

 

 

 

 

 

 

 

 

 

 

Motor speech

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Voice

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fluency/prosody

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pragmatics

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Swallow dysfunction

Preparatory

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Oral

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pharyngeal (suspected)

 

 

 

Date of first tx at this office for this condition _____/_____/______

 

 

 

 

Esophageal (suspected)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

Anticipated Release Date _____/_____/______

 

ICD-9 Code:

 

 

 

 

Description:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Additional Diagnostic Info

 

Prognostic Indicators

 

1. Primary

______________________________

 

___________________________________________

 

Videofluroscopy

□

 

Motivation

□

2. Secondary ______________________________

 

___________________________________________

 

Endoscopy

□

 

Cueing Responsiveness

□

 

 

CXR results

□

 

Active Caregiver Participation

□

 

 

 

 

 

 

 

 

 

 

 

 

 

3. Additional

______________________________

 

 

___________________________________________

 

Other (describe)

□

 

Safety Awareness

□

4. Additional

______________________________

 

 

___________________________________________

 

Summary:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Treatment Plan (MM/DD/YYYY)

 

Treatment Goals (Functional Improvement and Outcomes Expected)

 

Special Considerations:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Alternate nutritional delivery

 

From ________/_______/__________

 

 

 

 

 

 

 

 

 

 

Augmentive devices

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

To

_______/_______/___________

 

 

 

 

 

 

 

 

 

 

Tracheostomy/Ventilator

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No. of Visits Requested ___________

 

 

 

 

 

 

 

 

 

 

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I declare that the above information is true and correct to the best of my knowledge. Further, it is my professional judgment that speech therapy is not contraindicated for this patient. If I am required under state law to obtain a prescription prior to rendering this treatment, I have obtained such a prescription in compliance with state law.

Signature___________________________________________________________________________Date_________________________________

VL111913

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