Background information. Describe the client in terms of their diagnosis. Include data from the most recent evaluations and assessments, the most recent IEP and any relevant school reports. Also include parent or caregiver information that might be helpful.
Observations of client’s behavior. Describe the client in terms of their rapport with the clinician, how responsive they are to feedback (and what type of feedback is most helpful for them), and how resistive they are to completing tasks. You can also discuss any social behaviors or observations, unusual behaviors, or anything that supports their background info, such as behaviors consistent with their diagnosis.
Initial assessment. If you have assessed the client using a formal evaluation tool, describe that here. Give the baseline data for this assessment. If you are not using a formal assessment, just provide baseline data on your informal assessment. If you want to include a recent evaluation or diagnostic report, reference the data of that report and briefly summarize the results.
Treatment approach. Discuss the research based intervention approach that you focused your treatment on. For example, a traditional articulation therapy, the Cycles approach for phonological processing disorders, or the SCERTS program for autism.
Progress. List your goals and objectives here. Summarize the procedures you used to address each objective. Also discuss how you collected and organized your data for each session and how you organized the baseline and new data for the semester. Finally, state whether the client has met or not met their goals and why. You may want to state that if the goal has not been met, the client’s goal is still in progress. This provides and opening for the next clinician to continue treatment if the progress shows an improvement, and it provides a nice segue into the recommendations section of your report.
Home program. Did you provide the client or their caregiver any specific home training or carryover tasks? List them here. It might be a good idea to discuss whether or not the carryover program was successful (i.e., did you see improvement on weeks when the client practiced at home?). Also include any caregiver feedback about the types of home programming that the client was most responsive to and that fit best into their daily schedule.
Final assessment. This is where you can list any post-treatment assessment data, the dates of the formal testing, and the names of the test(s).
Current impressions and status. In this section, start by stating the current diagnosis and severity. Here you want to talk about additional behavioral observations that you have noticed over the treatment term. You can list things such as the client’s developmental expectations, strengths, challenges in therapy, home issues, academic and social functioning, and any other factors that are impeding or facilitating progress. End this section by discussing your thoughts on the client’s prognosis for improvement, based on treatment progress, family or home support, the age of the client, their attendance in therapy, and their motivation for improvement.
Recommendations. In this section, you can list where the client’s treatment may continue over the next treatment term or semester. Should the client’s treatment continue? If so, how often? A list of targets that the next clinician can focus on would also be helpful. Write this section as though you do not know who the next clinician or therapist is, because the client may not continue to receive therapy in the same location.
In my recommendations section, I also included any tips I
thought might be helpful for the child’s caregivers to facilitate their goals
at home. I based these tips on things that I noticed worked for the client in
our therapy sessions, such as using a pointer finger when reading, or offering
to help sound out the initial phoneme of unfamiliar words.
Happy writing!
