Fresno Scholarship Nomination

Your name

Your email

Your phone number

Child’s initials

Child’s age at this time.

Child’s age at the time of CAS diagnosis.

Did you provide the diagnosis? If not, who did?

Do you agree with the diagnosis?

Yes

No

Why not?

What are all of the child’s formal diagnoses?

How long have you been treating this child?

What percentage of speech is intelligible currently to an unfamiliar listener? The Intelligibility in Context Scale is a useful metric.

What is this child’s current severity level of CAS based on intelligibility rating and response to cuing, progress made thus far and concomitant conditions?

Is the child using AAC for communication currently? If so what is being used? Explain how successful the child is using it in all environments.

What are all of your current short-term goals for this child?

What therapy approach(es) are you using with this child currently?

How frequently are you providing treatment each week and what is the length of your sessions?

What is the prognosis for future progress on goals with your current therapy schedule?

What is your recommendation for the number/length of sessions (i.e. 3 times a week for 45 minutes each session) for this child for this year (if there were no barriers)? Include the length of time you feel intensive therapy would be beneficial (i.e. 4 times a week for 3 weeks and then a break of X# of weeks, then intensive therapy again).

What are the barriers for the child not receiving the recommended number of sessions?

Describe the level of family involvement. Do they follow through on home practice and implement your instructions?

What is the feasibility of the parent getting their child to therapy the recommended amount of time given any issues with scheduling i.e. managing their other children’s schedule, their work schedule, and your availability to increase the intensity of therapy?

Do you believe the child is able to handle intensive services? How is their emotional resilience?

If you are aware of any financial barriers, please give any information you have about the family’s financial status (only one income, other health related bills, low income, etc…).

Submit a report of child – most recent evaluation report or progress report that gives diagnosis information. Please upload .doc or .pdf files only

Maximum upload size: 516MB

Fresno Scholarship Nomination

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