Aphasia assessment report: a template for speech therapists

An aphasia assessment report is the document that describes an adult's language and communication difficulties after a brain injury, most often a stroke, and sets out the speech therapy diagnosis and the care plan. It goes to the prescribing doctor and into the patient's file.

Our general speech therapy assessment report template covers the general case. This page focuses on adults with aphasia seen in private practice in France, often a few weeks after leaving hospital.

What this document is for

First, it is for the doctor. The GP or neurologist wants to know where their patient's language stands, what you propose and what needs watching. They read quickly.

Second, it is a baseline. The initial assessment sets out the state of language on a given date. After a stroke, progress can be fast at first. A precise baseline lets you measure change at the reassessment and justify further care.

Third, it is for the patient and their family. A readable document helps a spouse understand why the patient understands better than they speak, or the other way round.

The framework

In France, speech therapists work on medical prescription. It is customary for the prescription to read as a speech therapy assessment with therapy if needed. According to the FNO professional booklet, the doctor no longer has to state the number of sessions. The speech therapist makes the speech therapy diagnosis and decides the number and type of sessions. The same booklet lists among the acts in neurological conditions the rehabilitation of spoken or written language linked to localised brain lesions, including aphasia, and of dysphagia.

In practice, the report, with the speech therapy diagnosis, goes to the prescriber. If the patient's GP is someone else, send them a copy with the patient's agreement.

The content is covered by professional secrecy (article L1110-4 of the French Public Health Code). Share with the care team what is useful for the patient's care, and no more.

The patient can ask to see the information in their file (article L1111-7 of the same code). According to service-public.fr, it must be provided within 8 days at most, or within 2 months for information over 5 years old. So write as if the patient might read it, because they might.

Tell the patient that the report is being sent and what it says. Aphasia does not remove the ability to consent, but it can make understanding harder. Take time to explain with simple words, gestures or a written support. You can involve the carer and give them a copy if the patient agrees.

The outline, section by section

Identification and medical context

Name, age, handedness, current or former occupation, first language and other languages, education. Then the neurological event, its date, the side and territory of the lesion as stated in the medical letter. Note the care pathway (hospital, rehabilitation unit, return home) and known treatments or deficits, such as hemiparesis or a visual problem.

Prescription

The prescriber's name, the date and the wording of the prescription. Note any previous speech therapy in hospital.

Complaint and history

Keep the patient's complaint separate from the family's. They often differ. Note the patient's previous way of life and what they hope to get back.

Testing conditions

Place, length, fatigue, alertness, glasses or hearing aids, whether a relative was present. If you use a standardised aphasia test battery, name it and report your results as you scored them.

Spoken expression

Describe fluency (rate, length of utterances, effort), word-finding difficulties and the strategies the patient uses to get round them. Note the type of paraphasias (phonemic, semantic, neologisms) with one or two examples. Comment on syntax and how informative the speech is. Put naming and repetition here, saying what helps the patient, such as a first-sound cue or a semantic cue. Flag any associated articulation disorder, such as dysarthria.

Comprehension

Understanding of words, simple sentences, complex sentences and instructions. Distinguish understanding in conversation, where context helps, from understanding in formal tasks. Note whether it drops with length, speed or background noise.

Written language

Reading aloud and reading comprehension, from words to texts. Spontaneous writing, copying and dictation. State which hand was used if the dominant arm is affected, so that a motor problem is not mistaken for a written language disorder.

Functional communication

How the patient makes himself understood day to day. Gestures, facial expressions, writing, drawing, help from others. Turn-taking, initiative in conversation, adapting to the other person. Then the concrete impact on daily life, such as the phone, shopping, paperwork or social life.

Summary and speech therapy diagnosis

In a few sentences, the profile of the disorder and its severity, the preserved abilities you can build on, and the speech therapy diagnosis. Flag any associated problems here. Difficulty swallowing or coughing during meals should be reported to the doctor promptly. Swallowing is also part of speech therapy, and you can suggest a specific assessment. For problems with memory, attention or recognition, suggest a referral, for example a neuropsychological assessment, without drawing conclusions for another professional.

Care plan

The goals of therapy, stated concretely and tied to what the patient wants. The planned frequency, adjusted to fatigue. The planned date of the next assessment.

Advice for family and carers

A few simple tips the carer can use the next day. Short sentences, one question at a time, leave time to answer, avoid finishing the patient's sentences. Most of it is passed on face to face.

A filled-in example

Fictional patient. Results are described without scores for the example. In a real report, give the results you scored.

Identification and medical context. Mr Henri P., 67, right-handed, retired carpenter, first language French. Left middle cerebral artery (sylvian) ischaemic stroke 6 weeks ago, according to the attached hospital report. Weakness of the right arm. Back home for 10 days, lives with his wife.

Prescription. Prescription from the GP, speech therapy assessment with therapy if needed. Speech therapy started during the hospital stay.

Complaint and history. Mr P. says "the words don't come". His wife notes that he gets annoyed when people do not understand him and that he avoids the phone. He wants to chat with his friends again and read his newspaper.

Testing conditions. Two 45-minute sessions at the practice, in the morning. Cooperative patient, tired by the end of each session. Wearing his glasses. Wife present for the history.

Spoken expression. Non-fluent speech, short utterances, visible articulatory effort. Frequent word-finding difficulties, partly offset by gestures and circumlocutions. Phonemic paraphasias, a few semantic paraphasias. In picture naming, a first-sound cue helps clearly. Repetition correct for short words, harder for sentences.

Comprehension. Good understanding of words and simple sentences in conversation. Difficulty with long sentences and multi-step instructions. Understanding drops when several people talk.

Written language. Can read common words, slow sentence reading with errors. Writes with his left hand because of the right-sided weakness, limited to single words, with spelling errors.

Functional communication. Mr P. makes himself understood for daily needs with gestures and context. Conversations outside the home are harder. He still wants to communicate and takes initiative in conversation.

Summary and speech therapy diagnosis. Moderate non-fluent aphasia, with word-finding difficulties, paraphasias, impaired understanding of complex sentences and impaired written language. Strengths: good motivation, effective non-verbal communication, available wife. No swallowing complaint and no coughing at meals according to his wife, to be monitored. Fatigue and slowness to be reported to the doctor, a neuropsychological opinion can be discussed.

Care plan. Intensive speech therapy at this stage, adjusted to fatigue. Goals: improve word retrieval, lengthen utterances, strengthen understanding of complex sentences, resume reading short texts, set up communication strategies with his wife. Next assessment planned in a few months.

Advice for family. Speak slowly, one idea per sentence, allow time, offer a choice of answers, keep gestures and writing as aids.

Common mistakes

• A report that lists tasks without concluding. The doctor is looking for the summary. Make it stand out.
• Labels without description. Writing "Broca's aphasia" without describing what the patient does is of little help. Concrete examples tell the doctor and the family more.
• Leaving out testing conditions. Fatigue, alertness, vision or hearing problems change how results should be read.
• Ignoring real-life communication. A patient may fail formal tasks and still be understood at home, or the reverse.
• Not flagging associated problems. A suspected swallowing disorder or a cognitive problem must appear clearly, with the suggested referral.
• Jargon the patient will not understand. They can ask for their file.

Save time with Delta

Delta is a clinical assistant for mental health and allied health professionals. During the history-taking, Delta transcribes what is said. After the session, you can also dictate your observations or add written notes.

Delta then drafts the report in your template, adapted to your profession. As the Delta page for speech therapists explains, it offers templates for assessments, therapy reports and letters to the prescribing doctor, and you can create your own. Delta does not calculate any score. Test choice, scoring and interpretation stay with you. Delta takes the results you scored, typed or dictated, and lays them out in the report. You review it before sending.

Data is hosted in France by an HDS-certified host, and AI processing takes place in France. The patient's name and identifying details are pseudonymised before the AI step. No audio file is kept. Data is never used to train a model.

Its limits are simple. Delta does not handle scheduling or billing. It is a recent tool built by a small team. The trial lasts 14 days with no credit card. After that, the Pro plan costs 29 euros per month incl. VAT billed annually (348 euros per year), or 35 euros per month incl. VAT with no commitment. A free plan is limited to 10 sessions per month.

Further reading

• Speech therapy assessment report, general template
• Letter to the prescribing doctor in speech therapy
• Speech therapy discharge report
• AI report software for speech therapists
• All our clinical document templates
• What is Delta?
• Delta for speech therapists

Frequently asked questions

Sources

• FNO, 2026 professional booklet (prescription, speech therapy diagnosis, acts in neurological conditions), in French, accessed 10 October 2026
• Service-public.fr, access to medical records, in French, accessed 10 October 2026
• Delta for speech therapists, accessed 10 October 2026