PRIVATE SPEECH PATHOLOGY PRACTICE
POLICY AND PROCEDURE MANUAL
Templates
2014
The Speech Pathology Association of Australia Limited
Level 2, 11-19 Bank Place, Melbourne, VIC 3000
Telephone: (03) 9642 4899
Facsimile: (03) 9642 4922
Email: office@speechpathologyaustralia.org.au
Website: www.speechpathologyaustralia.org.au
ABN 17 008 393 440

2014 The Speech Pathology Association of Australia Limited
Disclaimer: To the best of the Speech Pathology Association of Australia Limited’s (“the Association”)
knowledge, this information is valid at the time of publication. The Association makes no warranty or
representation in relation to the content or accuracy of the material in this publication. The Association
expressly disclaims any and all liability (including liability for negligence) in respect of the use of the
information provided. The Association recommends you seek independent professional advice prior to
making any decision involving matters outlined in this publication.
Introduction
The Speech Pathology Policy and Procedure Manual (P&P Manual) has been developed for
Speech Pathology Australia members who are working as private practitioners. The templates
included in this document are to be used as a guide only and need to be adapted by the speech
pathologist to suit their individual needs. The templates included in this document are not complete
and will be added to as required (particularly those that would be useful for private practitioners
working with an adult population). If you have an example of a template or a suggestion for a
template please email the information to Nichola Harris, SPA’s Professional and Clinical Support
Advisor by emailing advisor@speechpathologyaustralia.org.au
Other enquiries regarding the P&P Manual - Templates (or other professional practice issues) can
be directed to Speech Pathology Australia National Office staff by phoning 03 9642 4899 / 1300
368 835 or emailing office@speechpathologyaustralia.org.au.
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Contents
Each of the templates has been listed according to the order they appear in the P&P
Manual. Members are advised to refer to the corresponding policy and procedure before
adapting the template for their own use.
2. Communication between the speech pathologist and the client
2.1 Response to initial contact from potential new client
2.1 (b) SPA Template - Information for new clients
2.5 Confirmation of initial appointment
2.5 (a) SPA Template - Confirmation of Appointment letter
2.6 Information gathered and shared during the initial session
2.6 (a) SPA Template - Case history (general paediatric 0 – 6 years)
2.6 (b) SPA’s Template – Client Contact Details / Information (general paediatric 0 – 6
years) (under development)
2.6 (e) SPA Template - Initial session checklist
2.7(a)_ Speech and Language Assessment Report
2.7 (b) Speech and Language Initial Assessment Screen Report
2.8 Informing the client of the clinic policies
2.8 (a) SPA Template - Therapy Plan (paediatric)
2.9 Providing information about the homework requirements
2.9 (a) SPA Template - Homework sheet (paediatric)
3. Communication between the speech pathologist and other service providers
3.4 Handover to another speech pathologist
3.4 (a) SPA Template - Handover Report (under development)
5. Reporting to clients and other service providers
5.3 Reporting to third party funding sources
5.3 (b) SPA Template - Report to GP (CDM program)
5.3 (d) SPA Template - Report to GP (Follow up Allied Health Services for ATSI clients)
Same as 5.3 (b)
5.3 (h) SPA Template - Report to Paediatrician/Psychiatrist (HCWA and Better Start)
(under development)
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SPA Template
2.1 (b) Information for new clients
Example only – please individualize
(Clinician’s or Clinic’s Name)
ABN:
Speech Pathology
Information for new clients
Description of the service:
Staff:
Appointments: (Indicate when appointments are available)
Location of Practice: (Address)
Phone number:
Fax number:
Mobile number:
Referrals: (Explain e.g., Written referrals are not required.)
Cancellations: (Outline cancellation policy)
Parking: (Detail availability and/or restrictions)
Toilet/Access for disabled: (Detail if needed)
Fees: (Discuss fees e.g., The fee schedule overleaf lists the costs of consultations.)
Payment of fees: (Detail payment options).
Rebates: (Discuss rebates e.g., Speech pathology usually does not receive a Medicare
rebate. Some children are eligible for a Medicare rebate through the Chronic Disease
Management program and/or HCWA or Better Start Initiative. Access to these programs is
through your child’s GP or Paediatrician. Information sheets are available from the
clinician. Some private health insurance “extras” packages will provide a refund for speech
pathology services. Please advise the clinician which health fund you are with so that she
can provide you with the appropriate receipt.
Initial Consultation: (Detail what this involves e.g., The initial or first consultation is for
one hour. This consultation allows the clinician to gain background information about the
child and to screen the child’s current speech and language skills. Information is gathered
by discussing the child’s birth, developmental and medical history, as well as the parent’s
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SPA Template
2.1 (b) Information for new clients con’t
observations of the child’s speech and language skills. How the clinician screens the
child’s current skills depends on the child’s age. For younger children this may involve
observing the child playing with his/her parent. For older children the clinician may
administer screening tests. If no other assessment consultations are required a one page
summary of the screening consultation is provided free of charge to the parent.
A one hour (initial) consultation is usually sufficient for the assessment of:



Stuttering
Articulation (Speech)
Straight forward expressive language delay)
Assessment information: (Discuss what this involves e.g., The clinician will inform you if
a more comprehensive assessment is required and how many sessions this will entail and
the cost. The number of assessment consultations required will vary depending on the
child’s age and the type of communication difficulty.
Two or three consultations are usually required for the assessment of:




Receptive and Expressive Language Disorders
Speech Sound Disorders
Autism-Spectrum Disorders
Literacy Learning Difficulties
A kinder/school visit may be required as part of the assessment process.)
Assessment report: (Discuss when a report is supplied. How long after the assessment
will the client receive the report by and how much the report will cost.)
Fee Schedule
Insert table of fees.
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SPA Template
2.5 (a) Confirmation of Appointment letter
Example only – please individualize
(Clinician’s or Clinic’s Name)
ABN:
Speech Pathology
Address and
Contact Details
CONFIRMATION OF APPOINTMENT
Client name:
Clinician’s name:
Appointment date:
Time of session: XXX (please arrive a few minutes earlier if possible to fill in paperwork)
Length of session:
Address of clinic:
Phone number for clinic:
Session type: Screening assessment session or formal assessment session
Written report provided: Yes/No
If you have any questions please call me on XXXXX
If not I look forward to meeting you and XXXX on XXXXX
Regards,
XXXXX
Speech Pathologist
Member of SPA – CPSP
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SPA Template
2.6 (a) Case history (general paediatric 0 – 6 years)
Example only – please individualize
Clinic’s/Clinician’s Letterhead
Case History
Date: __________________
Name of clinician (completing case history): _________________________
Information gathered from: _______________________________________________
Client’s name: ______________________________
D.O.B/Age: ______________________________________
Reason for referral: ______________________________________________________
Source of referral: _______________________________________________________
Has your child ever seen a SP before? _______________________________________
Educational status: ______________________________________________________
Siblings: _________________________________________________________
Family history: __________________________________________________________
________________________________________________________________________
Birth History:

Pregnancy __________________________________________________________

Delivery ____________________________________________________________

Birth weight /APGAR_____________________________________________________

Special needs ________________________________________________________
Feeding History:

Breast or bottle fed ___________________________________________________

Solids ______________________________________________________________

Problems chewing ____________________________________________________

Drooling ____________________________________________________________

Thumb sucking
NO
YES
__________________________________________
SPA Template
2.6 (a) Case history (general paediatric 0 – 6 years)
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
Dummy
NO
YES_______________________________________________
Motor Milestones:

Crawling
YES
NO
_______________________________________________

Walked at __________________________

Well coordinated?
YES
NO
_______________________________________________

Have there ever been any concerns re motor skills?
NO
YES
________________________________________________________________________
__
Language Milestones:

Babbling
NO
YES
_____________________________________________________


First Words at ______________________________________

Sentences at ____________________________________
Have there ever been any concerns re language skills?
NO
YES
______________________________________________________________________________
_
Has the child’s speech always been clear?
YES
NO
______________________________________________________________________________
_________Current language status:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
___________________________
Medical History:

Illnesses/injuries ________________________________________________
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
Hospitalisation _______________________________________________________

Medication __________________________________________________________
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SPA Template
2.6 (a) Case history (general paediatric 0 – 6 years)
Audiology:

Formal hearing assessment ____________________________________________

History of ear infections _______________________________________________

Allergies/Asthma_____________________________________________________

Family history of epilepsy:

Other services/specialists: _____________________________________________
No
Yes ________________________________
________________________________________________________________________
Play: ___________________________________________________________________
________________________________________________________________________
_______________________________________________________________________
Receptive Lang: ________________________________________________________
_______________________________________________________________________
Expressive Lang: _______________________________________________________
_______________________________________________________________________
Articulation: ____________________________________________________________
________________________________________________________________________
Social skills: ____________________________________________________________
_______________________________________________________________________
OPE: __________________________________________________________________
Voice: _________________________________________________________________
Fluency: _______________________________________________________________
______________________________________________________________________________
_________
Other:
______________________________________________________________________________
______________________________________________________________________________
__________________
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SPA Template
2.6 (e) Initial session checklist
Example only – please individualize
(Clinician’s or Clinic’s Letterhead)
Initial session checklist
Client name: ________________________
Client contact details and information form completed
Any Court Orders
YES
If yes, do you have a copy
/
NO
YES
/
Date: _____________
YES
/
NO
NO
If no, when and how are you going to obtain a copy
_________________________________________
Referral source ________________________________________
Acknowledgement of referral required
YES
/
NO
If yes, date sent: ____________________________________
Alternative public services discussed
If not discussed why not?
/
NO
Already knows about/attended a public service
Funding sources discussed YES
Client eligible for:
YES
/
NO
Medicare – CDM
Medicare – HCWA
FaHCSIA – HCWA
FaHCSIA – Better Start
Conflict of interest disclosed
YES
/
NO
Collection statement discussed
YES
/
NO
Consent form completed
YES
/
NO
Case history completed
YES
/
NO
Medicare – Better Start
NDIS
/
Not applicable
/
Not applicable
Things to do before next session:
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SPA Template
2.7 (a) Speech and Language Assessment Report
Below are examples of formats for a diagnostic report and an initial assessment/screen report.
Members are encouraged to individualise the format to meet the needs of the intended audience.
Organisation or individual identification (letterhead)
Name:
D.OB:
Address:
Telephone:
Parents/Spouses: (if appropriate)
Date of evaluation:
Referral source:
Date of report:
Speech and Language Evaluation
CONFIDENTIAL
Presenting concern (Reason for referral)
Describe the presenting problem. Identify the referral source and reason for referral. State where
the information in the report was has been obtained.
History (Background)
Report information from referral letters, case history, and the parent/client interview. Report only
pertinent information relevant to the presenting concern. Areas covered may include:

Developmental history

Medical history

Family history

Educational or vocational status
Assessment Tools
List alphabetically tools administered using APA style (see below).
Evaluation (Assessment Results)
Summarise the results of assessment under the following headings:

Receptive Language

Expressive Language

Social Communication

Articulation

Voice

Fluency
Summary
Summarise and integrate the information from the history and evaluation sections of the report.
Diagnosis (Impressions)
If appropriate report the diagnosis. The diagnosis statement should be based on data and contain
a disorder classification, a specification of the severity of the symptoms and a statement of the
etiological and contributing factors.
Recommendations and Goals
Recommendations should be specific and brief. They may include recommendations for therapy,
parent/carer training, revaluation, and referral to other health professionals. If included, goals
should be clear and reflect the client’s needs and future therapy plans.
Signature /Date
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SPA Template
2.7 (b) Speech and Language Initial Assessment Screen Report
(Clinician’s or Clinic’s Letterhead)
Speech Pathology Initial Assessment Summary Report
Client name:
Date of Assessment:
Date of birth:
Age:
Background Information
(John Doe) attended a speech pathology initial assessment/screening assessment as (John’s)
parent/guardian reported concerns regarding his articulation skills. He is attending 4 year old
kinder and the kinder teacher has reported that she and the other children have trouble
understanding what John says. John is becoming frustrated by not being able to be understood.
There is a family history of delayed speech sound development with John’s older brother Tom
requiring speech therapy. There is no other medical or developmental history of note. Tom’s
hearing has not been assessed by an audiologist.
The following areas were assessed/screened (include all areas but indicate if an area wasn’t
assessed or screened).
Receptive Language (understanding of spoken language)
John’s receptive language skills were not formally assessed. Informal observations indicated age
appropriate skills in this area.
Expressive Language (spoken language)
John’s expressive language skills were assessed/screened using (name of assessment tool). John
presented with (describe results of assessment).
Oral Peripheral Examination
An oral peripheral examination was conducted. John’s articulatory structures including lips, tongue,
and velum appear to be (describe results of OPE).
Articulation/Phonology (speech skills)
John’s articulation and phonology skills were assessed using the (name of assessment tool). John
presented with (describe results of assessment).
Fluency
Informal observations indicated all parameters of fluency were unremarkable.
Voice
Informal observations indicated all parameters of voice and resonance were unremarkable.
Pragmatics (Social communication)
John’s pragmatic skills were assessed using (name of assessment tool). John presented with
(describe results of assessment).
Summary
John is a 4 year old 6 month boy who presented with (summarise assessment results).
Recommendations
1.
2.
3.
(Speech Pathologist’s name)
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(Date)
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Template
2.8 (a) Therapy Plan
Example only – please individualize
(Clinician’s or Clinic’s Letterhead)
THERAPY PLAN
Client’s name: _________________________
Date: __________________
Recommendation for therapy: (e.g., weekly, fortnightly, length of sessions, for how many weeks)
(e.g., Weekly therapy, 45 minutes per session for 10 weeks)
______________________________________________________________________________
_________
Day and date:
1
2
3
4
5
Attended:
Day and date:
6
7
8
9
10
Attended:
To assist your child to gain the most out of the therapy and to facilitate forward planning in the
clinic it is important that you attend each of the sessions allocated. If you cannot attend a session
due to illness we will try to make up that session on another day. Regular home practice is also an
essential part of the therapy regime.
Cancellation Policy: (e.g., If you cancel an appointment less than 24 hours prior to your
appointment time or fail to attend an appointment without due cause there is a charge of 50% of
the fee for the first cancellation and the full fee will be charged for subsequent non-attendance.)
Goals of therapy:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________
Clinician’ name:
Signature:
Date:
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CDM Program Team Member Feedback Form (Initial/Final session)
GENERAL PRACTITIONER DETAILS:
GPs Name: <<Doctor:Name>> Practice Fax: <<Doctor:Fax>> GP Email:<<Doctor:E-mail>>
Practice Name/Address: <<Practice:Name>> <<Doctor:Full Address>>
PATIENT DETAILS:
Patient Name: <<Patient Demographics:Full Name>>
Referred Date: <<Date referred to AHP by GP>>
Due Date>>
Date of Birth: <<Patient Demographics:DOB>>
GPMP/TCA Review Due Date: <<GPMP/TCA Review
FEEDBACK:
1. ASSESSMENT FINDINGS (including investigations and test results)
……………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………............
2. TREATMENT AIMS
……………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………….........
3. TREATMENT PROVIDED
……………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………….........
4. FUTURE MANAGEMENT
……………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………......……………...
5. REQUEST FOR FURTHER INFORMATION/INVESTIGATIONS FROM GP
……………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………
………………………………………………………………..…………………………....................................................................
..........................................................................................................................................................
6. OTHER COMMENTS:
……………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………….
ALLIED HEALTH PROFESSIONAL DETAILS
Name:
Medicare Provider Number:
Address:
Phone:
Fax:
Email:
Signature:…………………………………..Date…../…../…..
Please fill in form & return to GP one week before the above review date. Medicare require feedback to be
provided after the initial assessment and at the completion of the referral, and more often if needed.
This form has been recreated and adapted from a form developed by the Ballarat Division of General Practice Inc.
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