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.Format: (000) 000-0000.
If this individual is accepted, I would like to receive a copy of the report and follow up information after camp:
How would you like to receive information from camp?
Speech/Language Information
Is this child presently receiving speech/language services?
How many times a week?
For what length of time?
Diagnosis:
Speech/Language Disability in the areas of:

Other
How does this individual communicate?
Comments about this individual's communication:
Does this individual wear hearing aids?
Does this individual use a communication device?
If yes, what kind of device?
Will this individual be bringing a communication device to camp?
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
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Speech and Language Report

Therapist Information

Speech/Language Information