COWETA COUNTY SCHOOL SYSTEM

P.O. Box 280

Newnan, Georgia 30264

770-254-2810

Comprehensive Speech-Language Evaluation Summary

Evaluation Date:

Student Name: DOB:Chronological Age:

School:Grade:Teacher:

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I. Reason for Referral

II. Medical History

III. Developmental History

IV. Summary of Academic and Functional Performance

V. Second Language Considerations:

Is the student’s first language English? ____ Yes ____ No

If not English, what is the student’s first language? ______

Is the student English language proficient? ____ Yes ____ No

If not proficient, does the student receive ESOL services? ____Yes ____ No

VI. Speech-Language Assessment Summary

Vision Screening Results
Date: ____ Passed ____Failed / Hearing Screening Results
Date: ____Passed ____Failed

Articulation

Date / Test/Instrument / Standard Score / Interpretation

Intelligibility Rating (conversational speech) : _____ Good______Fair______Poor

Language

Date / Test/Instrument / Standard Score / Interpretation

Voice

Date / Test/Instrument / Standard Score / Interpretation
Characteristics of Voice: pitch high ____ low ____ WNL ____
quality hoarse ____ raspy ____ scratchy ____ WNL ____
intensity loud ____ soft ____ WNL ____
resonance hypernasal ____ hyponasal ____ WNL ____
Duration of problem prior to evaluation:
Examination by Medical Doctor: ____ yes ____ no (*If yes, attach report.)
Diagnosis ______
Medical or Surgical Intervention Required? ____ yes ____ no If yes, describe the treatment: ______
______
Physician ______
Address ______
Phone ______
* In the case of voice referrals:
If the student was referred for medical evaluation to rule out physical structure etiology as the cause of a voice or resonance impairment by a medical doctor, attach the medical documentation. The documentation should include a written order from the medical doctor regarding the medical evaluation and/or treatment that the student should receive. The medical orders may be considered as part of the eligibility process.

Fluency

Date / Test/Instrument / Standard Score / Interpretation
Types of Dysfluencies:
Secondary Characteristics:

Oral-Peripheral Examination Results: _____Passed _____ Failed

If failed oral-peripheral examination, describe problem(s)and results of follow-up assessments:
Behavioral Observations, e.g. was student cooperative, attentive, distracted, etc. ______
______
Are the evaluation results considered valid?
____ Evaluation results are considered valid. ____ Evaluation results should be interpreted with
caution. Reason: ______
______

Teacher and Parent Input

VII. Summary of Results

Is there adverse impact on educational performance (including social and behavioral performance)?
___ Yes ___ No
If yes, describe the adverse impact: ______
______
______

VIII. Recommended Interventions and/or Strategies

______

(Speech-Language Pathologist)

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