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SirAlexanderEwingIthacaCollegeSpeechandHearingClinic

IthacaCollege,Ithaca,NewYork14850

TreatmentPlan
*Allofthebelowinformationshouldbeomittedwiththeexceptionoftheclientsinitials,
supervisorsname,thecliniciansname,thedateoftheplan,andthediagnosis,andICD10
code.*

NAME: Insertinitials DATEOFPLAN: Insertdate


ADDRESS: DATEOFBIRTH:

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

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