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, Part 1: The Client File
This is the summary of Kelly's background, which you would review before starting your
session.
Kelly
• Age: 7 years old
• Grade: 2nd grade at a private school
1. Reason for Referral
• Primary Concern: Kelly is having significant difficulty learning to read.
• Source: Kelly's mother is requesting a comprehensive speech and language
evaluation at your private practice to get additional information about her
daughter's struggles.
• School Performance: Kelly is falling behind her peers, especially in reading and
math. She "hates sounding out words" and loses interest quickly when material
isn't clear.
• School Interventions: She has been receiving therapeutic services and extra help
at school because she wasn't keeping up with other students.
2. Relevant Background
• Strengths: Kelly is talkative and has a strong memory, which she relies on.
However, her reliance on memory makes it difficult for her to grasp new reading
and math concepts.
• Medical History: Kelly failed a vision screening at school.
• At-Home Efforts: Her mother has tried using flashcards and audio tapes to help,
but Kelly is still unable to understand the material.
3. Initial Clinical Hypothesis
• Kelly demonstrates possible reading and writing difficulties, likely rooted in
underlying language processing deficits. Her struggle with sounding out words is
a key indicator of possible phonemic awareness issues.
📋 Part 2: Assessment Results
These are the findings from the evaluation you completed prior to the intervention
session.