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IthacaCollege,Ithaca,NewYork14850
TreatmentPlan
*Allofthebelowinformationshouldbeomittedwiththeexceptionoftheclientsinitials,
supervisorsname,thecliniciansname,thedateoftheplan,andthediagnosis,andICD10
code.*
PHONE: AGE:
PARENTS: DIAGNOSIS: Insertdiagnosis
SUPERVISOR: Insertname ICD10CODE: Insertcode
CLINICIAN: Insertname
STATEMENTOFNEED(STATEMENTOFSPEECH/LANGUAGEPROBLEM)
SUMMARYOFTHERAPYHISTORY
CURRENTLEVELOFPERFORMANCE
LongTermGoals(Optionalbasedonnatureofdisorder)
ShortTermObjectivesandRationales(SemesterLength)
1.
Rationale:
2.
TreatmentPlan: Page
Rationale:
3.
Rationale:
StudentClinician ClinicalSupervisor
SignatureofPatientorGuardian Date
(Parentorguardianifclientisunder18)
REFERENCES(optional)
03/2016