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Speech Therapist
Speech Language Pathologist
Name
First
Last
Date
MM slash DD slash YYYY
Self-Assessment Rating Scale:
No Experience
Theory or observation only during the past 12 months
Limited Experience
Performed less than 12 times within the past 12 months and may need a review
Experienced
Performed at least once per month within the past 12 months and may need minimal assistance
Highly Skilled
Performed on at least a weekly basis over the past 12 months; proficient
Neurological
No Experience
Limited Experience
Experienced
Highly Skilled
Care of patient - Multiple sclerosis
Care of patient - Neuromuscular disease
Miscellaneous
No Experience
Limited Experience
Experienced
Highly Skilled
Aural rehabilitation
Family education
Fiber optic voice evaluation
Functional maintenance
Home health documentation
Inservice education
Medicare documentation
Transfer training
Video fluoroscopy
Video stroboscopic voice documentation
Therapy - Pediatrics
No Experience
Limited Experience
Experienced
Highly Skilled
Articulation
Care of child - Cerebral palsy
Care of child - Early interventione
Care of child - Learning disabilities
Care of child - Intellectual disability - Mild
Care of child - Intellectual disability - Moderate
Care of child - Intellectual disability - Profound
Care of child - Intellectual disability - Severe
Care of child - Traumatic brain injury
Fluency
Group treatments
Hearing impairments
Language
Screenings
Tracheostomy
Voice
Therapy - Adult
No Experience
Limited Experience
Experienced
Highly Skilled
Care of patient - Anoxia
Care of patient - CVA
Care of patient - Degenerative diseases
Care of patient - Laryngectomy
Care of patient - Intellectual disability - Mild
Care of patient - Intellectual disability - Moderate
Care of patient - Intellectual disability - Profound
Care of patient - Intellectual disability - Severe
Care of patient - Multiple sclerosis
Care of patient - Muscular dystrophy
Care of patient - Tracheotomy
Care of patient - Traumatic brain injury
Care of patient - Ventilator assisted/dependent
Fluency
Hearing impairments
Screening
Sign language
Voice
Therapy - Equipment
No Experience
Limited Experience
Experienced
Highly Skilled
Augmentative/alternate
Communication board
Communication devices
Feeding equipment
Memory aide
Procedures
No Experience
Limited Experience
Experienced
Highly Skilled
Bedside swallow evaluation
Compensatory techniques
Mechanical ventilation
Modified barium swallow
Thermal stimulation
Thickening agents
Signature
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