Screening Forms

The following forms are tools that I have used when screening elementary students. Theye were shared by by Bethany Ike on the ASHA Division 1 SIG list serve.



Pre-referral Interventions

The Minneapolis Public Schools Speech Pathology department has pre-referral intervention forms for language, articulation, voice and fluency disorders.
http://cityview.mpls.k12.mn.us/Speech_language_Prereferral_Interventions.html

Evaluation Data Review Form

This form can be used to collect data from a variety of sources to help document the need for an evaluation and to determine which of the SD disability categories need to be considered in the evaluation.

Score Conversion Chart

This chart converts standard scores to descriptive categories ranging from "significantly below average" to "significantly above average."

IEP and Evaluation Checklists




Goals & Objectives

NEW!! Vocabulary Goal Builder
This document contains a bank of condition, performance, and criterion statements that can be combined to develop individualized receptive and expressive vocabulary goals.




Medicaid

Information about billing Medicaid in South Dakota Public Schools is located at
http://legis.sd.gov/Rules/DisplayRule.aspx?Rule=67:16:37.


Parents must provide their signed consent before Medicaid benefits are accessed by the school district. This form can be personalized for your district to obtain consent. I send this form home with each student at the beginning of the school year in his or her homework folder and ask parents of new students who qualify for services to complete the form at the initial IEP meeting.


Therapy Log Sheets

The documents below are examples of therapy log sheets that I have used to document speech and language therapy services.
Contains fields to record all information needed for Medicaid billing and an open box to document session results.
Contains headers to cue SLP to record all information necessary for Medicaid billing, but has open lines for documentation rather than fields to record specific information about the session.
Contains fields for information needed for Medicaid billing and includes 10 "+/-" boxes per line to record student responses and easily calculate percent correct for the task.
Contains fields for the SLP to complete to record all information needed for Medicaid billing with separate boxes for the "Activity/Materials, Student Response/Progress" and "Comments."
This form does not include headers or fields for Medicaid billing, but has 10 "+/-" boxes per line to record student responses and easily calculate percent correct for the therapy task.

Performance Review

ASHA Professional Performance Review Process for the School-Based Speech-Language Pathologist
http://www.asha.org/docs/html/GL2006-00275.html#AP2