Raise your hands if you feel overwhelmed when told you MUST write a legally defensible speech and language assessment report? Anytime I am sitting in a department meeting and one of the administration team says “legally defensive”, my anxiety levels increase.

Every speech report I wrote flashes through my mind (especially in those early days). Would they hold up in a court of law? The realization that I may have written a speech and language assessment report that could one day be discussed in a courtroom where people could pick apart my skills, sends me into a state of panic.

Does anyone else feel a sense of panic?

This is me when I get an email or sit in a presentation about “legal” practices with IEPs and reports.

Collecting Background Information For Speech Assessments

Today, I wanted to share why including a thorough background information section in your speech and language assessment reports is important as well as a key component of writing a “legally defensive” report. I will also share what I include in my background information section and some of my tips on “how” to get that information in a timely manner!

Why do SLPs need to collect detailed background information?

It’s the law folks. Not only do we need to follow the eligibility educational code when doing assessments, but we also need to document that we tried interventions and considered all background information when determining eligibility.

We are showing the IEP team that we did our homework. It is important to gather information from many sources (i.e. parents, teachers, doctors) to show that we got to know our students and any important factors that could be impacting their scores on formal and informal measures.

These is also the areas where we discuss suspected areas of need. As we gather information from parents, the intervention team, medical information, etc. we can document those areas that may need to be assessed. This helps the SLP determine where they need to spend the bulk of their assessment. If teachers and parents share that people have a difficult time understanding the student, this means that a major portion of our assessment should be dedicated to looking at articulation and phonology development.

What should you include in your background information section

1. Include the student’s name, age, classroom grade level and level of support, and where they go to school.
2. Primary language- Documenting the languages the student speaks at home and in the classroom. This is where I include CELDT scores, years of English exposure, and how often and with whom they speak their primary and secondary languages. I may also include information regarding English Language Development and interventions used in the classroom.
3. Previous assessments, diagnoses, and therapy the child may have received from outside agencies or from previous assessments.
4. Documenting general education interventions- Student receiving Response To Intervention, and the outcomes of the interventions.
5. Stating how the student was referred to the speech therapist (i.e. parent, teacher, student study team, etc).
6. Reason for the assessment- is it an initial or triennial assessment and the purpose for conducting the assessment.

How can SLPs collect background information from families?

In California and specifically where I work, many school districts use a Student Assistance Plan (SAP) to document general education interventions.  A student study team meeting is held after tier 1 and tier 2 interventions have been implemented. I have trained my support staff and teachers to always invite me if there are speech and language concerns. This way, I can be there at the meeting to ask appropriate developmental questions, inquire about classroom interventions and find out about the family history of speech and language delays.

Why you should invest the time to get good background information

Already, I can hear people saying “I don’t have time to go to more meetings.” This my friends are very true, but I look at this additional time spent as a way to save time later. I find that if I do not make time to showcase my expertise as a speech and language pathologist, I get many referrals that have not considered the educational code for eligibility (7th percentile), teachers who have not completed general education interventions (which legally we need to do to show least restrictive environment) or have not considered a child’s background and primary language development. Going to these meetings helps me to gather good background information as well as determine if an assessment is warranted.

I try and have parents fill out a health and development questionnaire.  In the event that the parent hasn’t returned the forms, I rely on my teachers to help me because they sometimes see the parent during drop-off and pick up. My teachers are so awesome, they will make the parent fill it out right there at the moment, so we can get the information. In some cultures, I found that they are more transparent and upfront with medical professionals about health and family history. In those cases, I will ask my nurses to call parents to get that valuable information.

Need A Speech Therapy Report Template

One way to save time, in the long run, is to make templates of your speech reports. Over the years, I have written blurbs in different reports. I finally began compiling them all in one place, so I could easily reference them when I had a similar assessment. My speech report templates have SAVED me on those days when my brainpower is on zero. Click the links below to make your own Google Doc copy of the different templates. It has assessment descriptions, my speech report template, and some great blurbs for the summary and interpretation section of your report.

Assessment Battery Templates

Sample Speech and Language Report

Sample Summary Blurbs for Explaining Assessment Results

Up Next Is Assessment Tools

My next post in this series will be about choosing assessment tools and how to document that information in your report! I hope this was helpful!! What tips do you have for documenting background information?