I started out my career in 2009 working for a pediatric outpatient clinic. That clinic also contracted me to public schools, so I was a part of both realms right from the start. I spent six years proving both models of therapy simultaneously and then six years providing school based services only. I often get many questions from parents about the difference between school based services and clinic/medical based services.
One of the biggest questions I get: Why did my child qualify at the clinic but not at school?
I recently created a handout for one of my schools and I wanted to share this information here specifically for speech therapy (the handout was about speech, occupational, and physical therapy).
School Based Speech Therapy Services
This model of therapy focuses on the skills impacting the child’s education performance or their ability to access the curriculum. This means that there has to be a negative impact on academics to qualify. States and districts have guidelines that they follow and are governed by IDEA (Individuals with Disabilities Education Act).
Cost: FREE!
The criteria to qualify in the school system is a lot more involved and can be more lengthy than in a clinic.
To qualify in the schools, the answer has to be yes to the following questions:
Is there a disorder/disability present? (typically in the moderate to severe range that meets state/federal guidelines)
Is there an educational need?
Is there a need for specialized services?
Qualifying can not be based on the results of one test and can not be due to a lack of educational opportunities or second language acquisition.
A full and individual evaluation is used to determine eligibility in the schools. A combination of standardized tests, informal assessments, classroom observations, teacher interviews, caregiver interviews, and school records review (attendance, behavior, grades, etc..) must be used. This can typically take 30-60 days to complete (timelines vary state to state).
After an evaluation is competed, a team of professionals (typically teachers, therapists, and administrators) will determine if the child is eligible for services based on state and federal guidelines. Then a committee will meet (including caregivers) to determine the best plan for the student. Please note: “Speech Impairment” is an independent eligibility area in most states (meaning a child can receive speech therapy services if they are no other disabilities present). Physical and occupational therapy are not stand alone eligibility areas in the schools and can only be received under another qualifying area. In some states, schools require a prescription for therapy services (very rare with speech, typically only OT/PT).
Re-evaluation: Students must be re-evaluated every 3 years to determine eligibility for school services.
Therapy model: If your child qualifies in the school, an IEP (individual education program) will be made which may include goals, classroom accommodations, and a schedule of services. Therapy services will focus on skills the child needs to be successful in school. This is done during the school day and typically in group sessions with other students (schools can not guarantee individual therapy, unless there is a documented need for it, which is rare).
Least Restrictive Environment (LRE): In the schools, we want all children to remain in the general education classroom unless absolutely necessary to remove them. Some therapy services require the student to leave the classroom. The committee must consider LRE when making decisions about the IEP plan.
Clinic or Medical Based Speech Therapy Services
TThis model of therapy can vary per facility but it typically focuses on building skills to improve the quality of life. Many facilities use a patient centered or strength based model. This model may qualify students with mild to severe disorders/disabilities if the services are determined to be medically necessary through an evaluation.
Cost: Depends on insurance coverage. It can be expensive if you are paying out of pocket or if your provider is private pay only.
Qualifying: It is not governed by a specific agency. Most require a referral from a physician and some or all of the following:
Results of standardized tests and observations that indicate below average skills.
Clinical judgement/professional opinion of the therapist.
Criteria set by Medicaid or Insurance (some require pre-authorization).
To qualify: A child is typically scheduled for an evaluation that is completed within one or two appointments. The therapist will administer standardized tests, observe the child, interact with child (typically through play), and give the caregivers checklists/forms to fill out. A child will receive a diagnosis if a disorder is present to begin therapy (in the applicable areas for speech, occupational, or physical therapy).
Medicaid/Insurance: Some require the initial evaluation to be submitted for approval before they will pay for therapy sessions. The number of sessions authorized may be limited by the insurance policy (i.e. 12 sessions per term).
Private pay: If your provider is private pay only, you may be able to begin therapy immediately after a disorder or delay was determined by the initial evaluation.
Re-evaluation: This varies by insurance and by providers, but typically a child must be re-evaluated every 6-12 months.
Therapy model: The therapist will write goals and objectives to target the areas of need identified in the evaluation. Therapy will focus on those skills. This is typically done in individual sessions at a clinic or in the client’s home, if it is home health services. The therapist will determine how many sessions per week the student will need to make progress.
Frequently asked questions
Why did my child qualify in the clinic but not in the school?
Your child may have presented with a mild delay or disorder (not meeting state or federal guidelines for eligibility)
Your child may not have a negative educational impact (their grades are good, they are performing on grade level, etc..).
Your child may not need specialized services (their teacher can assist them in the general education classroom).
Why does my child receives direct services in the clinic but only consult services in the schools?
Your child’s therapist may be able to provide staff training, observations, and consultations with the teacher to meet your child’s needs without having to remove them from class regularly. They may meet with your child periodically (remember least restrictive environment? )
Can my child receive both clinic/medial and school based therapy services?
Yes, you may choose to take your child to outside therapy services even if they receive school services (you will be responsible for the cost). It is helpful if you provide your plan of care with the school therapist and the IEP with the private therapist. In a perfect world, the providers would work together but remember, school services have to focus on helping the child succeed in the school environments (private SLPs are not bound to this). You may notice a difference in goals based on this.
Sample scenario where a child may qualify for clinic based services but not school based services:
A 10 year old child has a mild articulation disorder (standard scores and percentile ranks did not fall within state guidelines for eligiblity). The student has noticeable speech errors but they are not impacting his overall intelligibility. The errors are not impacting his reading or writing skills (the student is able to compensate even though he mispronounces some words). The student is on the A and B Honor roll, has good relationships with peers and adults.
In this scenario, the student does not demonstrate an educational need for services (the mild articulation disorder is not impacting his ability to be successful at school). The student may qualify for services in a clinic based on developmental norms and the potential of disruptions to activities of daily living (speaking and communicating with peers/adults and functioning in the community). Clinic based services typically can qualify a student that is in the mild severity range.
Clipart by https://www.teacherspayteachers.com/Store/Speakeazyslp