Speech Therapy Treatment Plan Form – Fill Out and Use This PDF

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:

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: