Complete SLP initial evaluation template with all required sections. Use this free template as a reference or let SOAP Note Buddy auto-fill your evaluations in any EHR.
What is a Speech-Language Pathology Evaluation?
A speech-language pathology evaluation (also called an SLP eval, speech therapy assessment, or initial evaluation) is a comprehensive assessment performed by a speech-language pathologist to evaluate communication, swallowing, and/or cognitive-communication abilities. It establishes baseline functioning, identifies disorders and their severity, determines diagnosis and prognosis, and creates the treatment plan.
The SLP evaluation is the foundation of effective speech therapy services. It serves multiple critical purposes:
Diagnostic Determination: Identifies the presence, type, and severity of speech, language, swallowing, or cognitive-communication disorders
Medical Necessity: Establishes why skilled speech-language pathology services are needed
Baseline Documentation: Creates measurable baselines for tracking progress
Treatment Planning: Guides goal development and intervention selection
Reimbursement: Supports billing for evaluation codes (92521-92524, 92610)
Communication: Informs families, educators, and other healthcare providers about findings
SLP Evaluation CPT Codes
SLP evaluations use specific CPT codes: 92521 (speech fluency), 92522 (speech sound production), 92523 (speech sound production with language), 92524 (voice and resonance), and 92610 (swallowing/dysphagia). Select codes based on the areas evaluated during the assessment.
What Does an SLP Evaluation Include?
A complete speech-language pathology evaluation follows a structured format that includes several essential components. Each section builds upon the previous to create a comprehensive picture of the patient's communication or swallowing abilities.
1. Case History
Comprehensive background information including demographics, referral reason, developmental milestones, medical history, educational history, prior therapy, and family/caregiver concerns. For pediatric patients, this includes birth history, developmental milestones, and school performance. For adults, this includes onset of symptoms, medical events, and prior level of function.
2. Oral Mechanism Examination
Assessment of the structure and function of the oral motor system. Includes examination of lips, tongue, jaw, hard and soft palate, dentition, and velopharyngeal function. Documents symmetry, range of motion, strength, coordination, and any structural abnormalities that may impact speech or swallowing.
3. Standardized Testing
Administration of formal, norm-referenced assessments appropriate to the referral concern. May include tests for articulation, phonology, receptive language, expressive language, pragmatics, voice, fluency, literacy, or cognitive-communication. Provides standard scores, percentile ranks, and age equivalents for comparison to normative data.
4. Clinical Observations
Informal assessment and observations during structured and unstructured activities. Includes speech intelligibility ratings, language sample analysis, observations of pragmatic skills, voice quality descriptions, fluency counts, and functional communication observations. Documents what the patient can do in real-world contexts.
5. Evaluation Summary and Recommendations
Synthesis of all findings including diagnosis, severity rating, prognosis, and specific treatment recommendations. Includes measurable short-term and long-term goals, recommended frequency and duration of therapy, and coordination with other professionals. May include referrals for additional testing or services.
Types of SLP Evaluations
Speech-language pathologists conduct different types of evaluations depending on the patient's presenting concerns. Each type requires specialized knowledge and assessment tools.
Speech Sound/Articulation Evaluation
Assesses the motor production of speech sounds, including articulation disorders and phonological processes.
Single word articulation testing (GFTA-3, Arizona-4)
Connected speech sample analysis
Phonological process analysis
Stimulability testing
Intelligibility ratings in various contexts
Oral motor examination for motor speech disorders
Language Evaluation
Evaluates receptive and expressive language abilities across semantics, syntax, morphology, and pragmatics.
Standardized language testing (CELF-5, PLS-5, OWLS-II)
Resonance assessment for velopharyngeal dysfunction
Fluency/Stuttering Evaluation
Evaluates speech fluency, identifying the presence, type, and severity of stuttering or other fluency disorders.
Stuttering severity instruments (SSI-4)
Disfluency type and frequency analysis
Secondary behaviors observation
Attitudes and impact assessment (OASES, CAT)
Speaking rate calculation
Situational variability assessment
Complete Speech Therapy Evaluation Template
Below is a comprehensive SLP initial evaluation template. You can use this as a reference for manual documentation or let SOAP Note Buddy auto-generate evaluations in your EHR.
Patient Information
Patient Name
[Patient Name]
Date of Birth
[DOB]
Chronological Age
[Years;Months]
Date of Evaluation
[Date]
Referral Source
[Physician, School, Self-referral]
Primary Language
[Language(s) spoken]
Referral Reason/Chief Complaint
[Primary concerns prompting the evaluation, in patient/family words when possible]
Diagnosis/ICD-10 Codes
[Primary and secondary diagnoses with ICD-10 codes]
Case History
Medical History
[Relevant medical diagnoses, hospitalizations, surgeries. For neurological patients: stroke date/type/location, TBI details, progressive diagnosis timeline. Include hearing and vision status.]
Developmental History (Pediatric)
Birth and Prenatal History
[Pregnancy complications, gestational age, birth weight, NICU stay, feeding difficulties]
Developmental Milestones
[First words, first sentences, motor milestones. Note any delays or regression. Include age when milestones were achieved.]
Prior Speech-Language Services
[Previous therapy history, duration, frequency, focus areas, discharge status and reason]
Educational/Vocational History
[Current grade/school placement, IEP/504 status, special education services. For adults: occupation, educational level completed.]
Social History
[Living situation, family composition, communication partners, languages in home, caregiver involvement]
Current Medications
[List current medications, particularly those that may affect cognition, voice, or swallowing]
Patient/Family Concerns and Goals
[What the patient and/or family wants to achieve from speech therapy - in their own words. Include functional communication goals and priorities.]
Oral Mechanism Examination
Facial Observations
[Facial symmetry at rest and during movement, presence of droop or weakness, nasolabial fold symmetry]
Lips
[Structure: symmetry, presence of cleft or scarring. Function: rounding, retraction, pucker, bilabial seal, strength, range of motion, speed of movement]
Tongue
[Structure: size, symmetry, presence of fasciculations. Function: protrusion, lateralization, elevation, depression, range of motion, strength, coordination for lingual-alveolar sounds, diadochokinetic rates]
Jaw
[Range of motion, symmetry of movement, TMJ clicking or deviation, jaw strength, jaw grading during speech]
Hard and Soft Palate
[Hard palate: intactness, height, width. Soft palate: symmetry, elevation during phonation (/a/), presence of bifid uvula, signs of submucous cleft]
[Observations of nasal emission, hypernasality, hyponasality during speech. Mirror test results if performed. Recommendations for instrumental assessment if indicated.]
Diadochokinetic Rates
[AMR: /pa/, /ta/, /ka/ repetitions per second. SMR: /pataka/ sequences per second. Note any breakdowns in coordination or sequencing.]
Standardized Testing
Tests Administered
[List all standardized tests administered with full names and versions.
Example:
- Goldman-Fristoe Test of Articulation-3 (GFTA-3)
- Clinical Evaluation of Language Fundamentals-5 (CELF-5)
- Peabody Picture Vocabulary Test-5 (PPVT-5)
- Expressive Vocabulary Test-3 (EVT-3)]
Test Results
[Document scores for each test including standard scores, percentile ranks, and age/grade equivalents.
Example format:
GFTA-3:
- Sounds-in-Words: Standard Score 78 (7th percentile)
- Sounds-in-Sentences: Standard Score 82 (12th percentile)
CELF-5:
- Core Language Score: 72 (3rd percentile)
- Receptive Language Index: 75 (5th percentile)
- Expressive Language Index: 70 (2nd percentile)
- Language Content Index: 74 (4th percentile)
- Language Structure Index: 71 (3rd percentile)]
Interpretation of Standardized Scores
[Explain what the scores mean in terms of severity and functional impact. Note any discrepancies between subtests and possible explanations.]
Clinical Observations
Speech Production
Articulation/Phonology
[Sound errors observed (substitutions, omissions, distortions, additions). Phonological patterns present. Stimulability for error sounds. Consistency of errors.]
Intelligibility
[Estimated intelligibility percentage in known context, unknown context, and with unfamiliar listeners. Impact on functional communication.]
Motor Speech Observations
[Observations related to apraxia of speech or dysarthria: prosody, groping, inconsistency, rate, precision]
Receptive Language
[Ability to follow directions (1-step, 2-step, multi-step), comprehension of questions (yes/no, wh-questions), understanding of vocabulary, comprehension of grammar/syntax, comprehension of paragraphs/stories]
Expressive Language
[Vocabulary diversity, mean length of utterance (MLU), grammatical structures used, word retrieval abilities, sentence formulation, narrative skills, conversational discourse]
Pragmatic/Social Communication
[Eye contact, turn-taking, topic maintenance, topic initiation, requesting, commenting, responding to questions, use of gestures, understanding of nonverbal cues]
[Sentence structures used, grammatical errors noted, word-finding difficulties, cohesion, topic maintenance, comparison to age expectations]
Evaluation Summary / Clinical Impression
Summary of Findings
[Narrative synthesis of all evaluation findings. Explain how standardized testing, clinical observations, and case history information come together to form your clinical impression.]
Diagnosis
[Speech-language diagnosis with severity rating.
Examples:
- Mixed receptive-expressive language disorder, moderate severity
- Speech sound disorder (phonological), moderate-severe
- Oropharyngeal dysphagia secondary to CVA
- Childhood apraxia of speech, moderate severity
- Fluency disorder (stuttering), mild-moderate]
Severity Rating
[Within Normal Limits / Mild / Mild-Moderate / Moderate / Moderate-Severe / Severe / Profound]
Prognosis
[Excellent / Good / Fair / Guarded / Poor - with supporting factors]
Prognostic Indicators
[Factors supporting prognosis: stimulability, motivation, family support, cognitive status, time post-onset (for acquired disorders), responsiveness to cueing during assessment]
Recommendations
Recommendation for Services
[Speech-language therapy is / is not recommended. Frequency and duration: e.g., 2x/week for 30 minutes for 12 weeks]
Short-Term Goals (1-3 months)
[Measurable, time-bound goals expected to be achieved within 1-3 months.
Example format:
1. Patient will produce /s/ in the initial position of words with 80% accuracy in structured activities within 8 weeks.
2. Patient will follow 2-step directions with 80% accuracy within 8 weeks.
3. Patient will use 3-4 word utterances to make requests with minimal cueing in 80% of opportunities within 8 weeks.]
Long-Term Goals (3-6 months or discharge)
[Functional outcomes expected by discharge.
Example format:
1. Patient will produce /s, z/ clusters in conversational speech with 90% accuracy.
2. Patient will demonstrate age-appropriate receptive language skills.
3. Patient will use complete sentences in conversation independently.]
Recommended Treatment Approaches
[Specific therapy approaches and methods to be used.
Examples:
- Cycles approach for phonological processes
- PROMPT for motor speech disorders
- Focused stimulation for language
- Lee Silverman Voice Treatment (LSVT) for Parkinson's
- Hanen strategies for parent training
- AAC implementation]
Home Program/Carryover Recommendations
[Activities for family/caregivers to support carryover between sessions, including specific strategies and frequency recommendations]
Additional Referrals/Recommendations
[Referrals for audiology, ENT, neurology, psychology, developmental pediatrician, MBSS, FEES, etc. if indicated]
Signatures
Evaluating Clinician
[Signature]
Credentials
[MA/MS CCC-SLP, CF-SLP, etc.]
License Number
[State License #]
Date
[Date]
Supervising SLP (if applicable)
[For CF-SLPs or SLP assistants - supervisor signature and credentials]
Tips for Writing SLP Evaluations
Writing thorough yet efficient SLP evaluations is a skill that develops with practice. Here are strategies to help you document more effective evaluations.
Select Appropriate Assessments
Choose standardized tests based on the referral concern, patient age, and cultural/linguistic background. Not every evaluation needs every test - select assessments that will answer the clinical questions and inform treatment planning. Document your rationale for test selection.
Document Functional Impact
Beyond test scores, explain how communication or swallowing deficits affect the patient's daily life. "Unable to order at restaurants due to intelligibility" or "Requires multiple repetitions from teachers" demonstrates real-world impact that supports medical necessity.
Be Specific and Measurable
Instead of "language is delayed," write "receptive language skills at the 5th percentile with specific difficulty following 2-step directions." Specific baselines allow you to track progress over time.
Write SMART Goals
Goals should be Specific (target skill), Measurable (percentage accuracy, frequency), Achievable (realistic given severity), Relevant (functional), and Time-bound (target date). Bad goal: "Improve articulation." Good goal: "Patient will produce /r/ in initial position of words with 80% accuracy in structured activities within 8 weeks."
Consider Cultural and Linguistic Factors
Document the patient's language background and consider how this may affect assessment results. Use appropriate norms, interpreters, or dynamic assessment when standard tests may not be valid. Document any modifications made to testing.
Synthesize, Don't Summarize
The evaluation summary should demonstrate your clinical reasoning - not just repeat findings. Explain how the pieces fit together, why you reached your diagnosis, and what factors influenced your treatment recommendations.
Insurance Documentation Tip
Ensure your evaluation clearly documents medical necessity. Include the diagnosis, severity, impact on function, and why skilled SLP services (not just practice at home) are required. This reduces claim denials and supports authorization requests.
How SOAP Note Buddy Helps with SLP Evaluations
SLP evaluations are comprehensive documents that can take 45-60 minutes or more to write manually. That's time spent after hours instead of with patients or family.
Generate Complete Evaluations in Minutes
SOAP Note Buddy uses AI to dramatically speed up your evaluation documentation. Enter your patient's key findings and the AI generates a complete evaluation draft in your EHR.
What SOAP Note Buddy Does:
Auto-Detects Your EHR Fields: Works with SimplePractice, Fusion, TherapyNotes, Raintree, and any web-based system
Generates All Sections: Case history, oral mech, test results, observations, summary, and recommendations
Writes Appropriate Goals: AI creates SMART goals based on your assessment findings
Understands SLP Terminology: Uses correct clinical language for phonemes, MLU, IDDSI levels, and standardized test names
HIPAA Compliant: Patient information is protected with automatic PHI removal
What used to take 45-60 minutes now takes 5-10 minutes of review and customization. That's 35-50 minutes saved per evaluation.
AI Documentation Best Practices for SLP Evaluations
Enter Accurate Test Scores: The AI generates based on what you provide. Accurate scores lead to accurate severity ratings and goals.
Review Clinical Reasoning: AI helps with structure, but add your own insights to the summary and clinical impression sections.
Customize Goals: Adjust AI-generated goals to reflect your specific treatment approach and patient priorities.
Verify Standardized Test Names: Confirm the AI uses the correct test names and versions you administered.
Frequently Asked Questions
What should be included in an SLP evaluation?
A comprehensive SLP evaluation includes case history (demographics, referral reason, developmental and medical history), oral mechanism examination (structure and function of the speech mechanism), standardized testing appropriate to the referral concern, clinical observations, evaluation summary with diagnosis and severity rating, prognosis, and treatment recommendations with measurable goals. The specific components vary based on whether you're evaluating speech, language, swallowing, or cognitive-communication.
How long should a speech therapy evaluation take?
A typical SLP evaluation takes 60-90 minutes for the patient session, depending on the complexity and areas being assessed. A comprehensive language evaluation may take longer than an articulation-only assessment. Documentation can take an additional 30-60 minutes if done manually. Using AI documentation tools like SOAP Note Buddy can reduce documentation time to 5-10 minutes of review.
What is the difference between a speech evaluation and language evaluation?
A speech evaluation focuses on the motor production of sounds - articulation, phonology, motor speech disorders (apraxia, dysarthria), voice quality, and fluency. A language evaluation assesses comprehension and expression of words and sentences - receptive and expressive language, vocabulary, grammar, pragmatics, and literacy skills. Many evaluations assess both speech and language, as they often co-occur and impact each other.
What standardized tests are commonly used in SLP evaluations?
Common tests include: articulation tests (GFTA-3, Arizona-4), comprehensive language assessments (CELF-5, PLS-5, OWLS-II), vocabulary measures (PPVT-5, EVT-3), phonological assessments (KLPA-3, HAPP-3), motor speech evaluations (VMPAC, DEMSS), fluency assessments (SSI-4), voice assessments (CAPE-V), cognitive-communication tests (CLQT, RIPA-2), and dysphagia evaluations (MBSS, FEES). Test selection depends on the patient's age, referral concern, and clinical presentation.
How do you write SLP evaluation goals?
SLP goals should be SMART: Specific (target skill or sound), Measurable (accuracy percentage or frequency count), Achievable (realistic given severity and prognosis), Relevant (functional and meaningful to the patient), and Time-bound (target date for achievement). Example: "Patient will produce /r/ in all positions of words with 80% accuracy in structured activities within 12 weeks." Goals should address both short-term skill building and long-term functional outcomes.
What CPT codes are used for SLP evaluations?
SLP evaluations use specific CPT codes based on the areas assessed: 92521 (fluency evaluation), 92522 (speech sound production evaluation), 92523 (speech sound production with language comprehension and expression), 92524 (voice and resonance), and 92610 (swallowing evaluation). Select codes that accurately represent the areas you evaluated during the assessment session.
Can a speech-language pathology assistant (SLPA) conduct evaluations?
No, only licensed Speech-Language Pathologists (SLPs) with the CCC-SLP credential can conduct evaluations and establish diagnoses. SLPAs work under the supervision of a licensed SLP and assist with treatment but cannot perform evaluations, make diagnostic decisions, or modify treatment plans. Clinical fellows (CF-SLPs) can conduct evaluations under supervision of a CCC-SLP mentor.
How can AI help with SLP evaluations?
AI documentation tools like SOAP Note Buddy can significantly reduce evaluation documentation time. Enter your assessment findings and the AI generates a complete evaluation draft including all sections. You review and customize the output, saving 35-50 minutes per evaluation. The AI understands SLP terminology, standardized test formats, and goal writing conventions, making your documentation more efficient while maintaining clinical quality.