Download Clients Initials: Age:

Diagnostic Plan
Client Initials:
Age:
Gender: M / F
Grad Student Clinician Goal:
Grad Student Clinician Goal:
INPUTS
(Available Background Info.)
Concern(s) (Referral Questions):
PROCESS
(Protocol you have planned in order to answer
the referral questions and concerns)
Brief Initial Phone Call:
 Do NOT email
 Meet with your supervisor first
 You cannot speak to anyone else (SLP)
without permission from the family
 Confirm appointment day/time
 Request child’s game preferences
 If collecting audio/video sample from
home, have them use UVM file transfer
for big files (be aware of HIPAA)
OUTCOME
(Verify or rule out the following diagnostic
hypotheses):
H1
H2
H3
Other desired outcomes:
Diagnostic Protocol:
More information needed about:

(If two students are assigned to a diagnostic evaluation, you cannot both get hours for the same activity. Both students must be actively engaged
and performing distinct activities (e.g., parent interview and collecting a language sample or collecting data to check reliability of scoring).