Members of a DSHA working group have designed the Speech-Language Information for Transition to IEP form for use by LICENSED SLPs. It is the working group’s hope that this form will play a positive role in ensuring a smooth transition for children at their third birthday by opening up the lines of communication between the Birth-to-Three (EI) SLP and the School-based SLP. The form has been designed to easily communicate the most up-to-date picture of the transitioning child’s speech/language skills in preparation for the Eligibility/IEP-development phase of the transition process. Please note that the form is meant to be a supplement to progress updates. If progress updates capture the information contained on this form, there may be no need to use the form. It is suggested that the form be completed and shared with the school-based program at least 60 days prior to the child’s third birthday. Completion is VOLUNTARY.
DISCLAIMER:
This form is intended for use by LICENSED SPEECH-LANGUAGE PATHOLOGISTS ONLY to assist in communicating with other SLPs as children transition from Part C to Part B services. This form is NOT meant to be included as part of the child’s audit file. It is the sole responsibility of the Speech-Language Pathologists using this form to ensure that its use meets the privacy standards outlined by HIPAA, FERPA, and any other relevant governing bodies (such as practices specific to agencies, state and federal privacy guidelines, etc.). The Delaware Speech-Language-Hearing Association is providing this form as a resource, and will not be held liable for any inappropriate use of this form.
SLPs may want to consider:
- Obtaining a signed “Release of Information” from the child’s parent/guardian granting permission to share information about their child with the school-based SLP.
- Avoiding use of identifying information such as full or last name, birthday, address of child, etc. Depending on the information being shared, transmission of the form via fax, or via end-to-end HIPAA encrypted email may be considered. In-person delivery would best support secure transmission.
- Using a disclaimer when using this form such as, “The information contained in this transmission may contain privileged and confidential information, including patient information protected by federal and state privacy laws. It is intended only for the use of the person(s) named above.”
- Password protecting the document (Refer to these links for Microsoft Word documents, Apple Pages documents, or PDF for directions about password protecting documents).
Download the form (in .pdf format) by clicking here. For Microsoft Word or Apple Pages format, please send an email indicating your preferred format to dsha@37.60.248.149.
Completing the form:
Information related to the SCALE Section:
(M) = Mastery…the skill is observed at least 80% of the time.
(E) = Emerging…the skill has been observed, but is not yet used consistently.
(N) = Not Present…the skill has yet to be observed.
Information related to the GREATEST AREAS OF NEED Section:
Examples: articulation (stimulability), observed phonological processes, sensory processing needs, examples of assistive technology (AT) trialed/used (AT type, information about trials, etc.), description of any feeding issues or concerns, other early intervention services the child receives (e.g., ECE, PT, OT, services for hearing impairment, etc.) and any information that will provide a comprehensive picture of the child’s abilities and needs.
