Speech and Language Report for Elks Camp Grassick

Speech and Language Report

for Elks Camp Grassick
To be completed if this child is receiving or could benefit from speech therapy while at camp. Please include a copy of the child's IEP or speech goals with the application.
Name of Applicant*

First NameLast Name
Birth Date*

MonthDayYear
Therapist Information
Name of Individual's Speech Language Pathologist*
Speech Therapist's Email*
example@example.com
School System or Agency of SLP:*
Address of School or Agency*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of School or Agency*
Please enter a valid phone number.
If this individual is accepted, I would like to receive a copy of the report and follow up information after camp:*

YesNo
How would you like to receive information from camp?

I would like to receive paper copies in the mail.I would like to receive digital copies by email.I would like to receive paper and digital copies.
Speech/Language Information
Is this child presently receiving speech/language services?*

YesNo
How many times a week?
For what length of time?
Diagnosis:
Speech/Language Disability in the areas of:*

Minor ArticulationMajor ArticulationOral Motor Control/CoordinationReceptive LanguageExpressive LanguagePragmatic/Social LanguageGrammarSemanticsFluencyHearingOther
How does this individual communicate?*

VerbalNon-VerbalVocalizesCommunication deviceSignEye GazeResponds to ChoicesGestureLeading adult to desired item/activity
Comments about this individual's communication:
Does this individual wear hearing aids?*

YesNo
Does this individual use a communication device?*

YesNo
If yes, what kind of device?
Will this individual be bringing a communication device to camp?

YesNo
Please describe the individual's level of independence with his/her communication device.
Please describe the individual's motivation to use his/her communication device.
What materials, programs, special equipment, etc. are being used with this individual?*
Please give a brief description of therapy this individual is presently receiving, and concerns being addressed in the school/clinical therapy setting, including the level of support/cueing that this individual needs to be successful.*
Please give some suggestions or specific areas of concentration you would like our speech/language personnel to work on with this individual while at camp. (Please keep in mind the time frame they will be at camp.*
Please upload any pertinent files here.

Cancelof
Should be Empty:

Speech and Language Report

Therapist Information

Speech/Language Information