Westchester County --Early Intervention Program-SESSION NOTE-10/1/15 Important Steps, Inc.Child’s Name: DOB: _/ / Sex: Male Female EI #: IFSP Mandate: ____Auth#:_______________Interventionist’s Name: Credentials/Disciple: National Provider ID #: Service Type:Session Date: / / IFSP Service:__ Location: Home Community Facility Time: From AM PM To AM PM
Session Date: / / IFSP Service:___ Location: Home Community FacilityTime: From AM PM To AM PM
ICD-10 code: ______________HCPCS Code (if applicable): __________________ 1st CPT Code: ____2nd CPT Code: ______ 3rd CPT Code:______4th CPT Code:___ _
ICD-10 code: ______________HCPCS Code (if applicable): __________________ 1st CPT Code: ____2nd CPT Code: ______ 3rd CPT Code:______4th CPT Code:___ _
Session cancelled - reason listed in #1. This is a make-up for a missed session on / / . (must be within 2 weeks) Session Participants: child parent/caregiver Other: Parent/Caregiver unable to participate during session due to:____________________
Session cancelled- reason listed in #1. This is a make-up for a missed session on / / .(must be within 2 weeks) Session Participants: child parent/caregiver O Other: Parent/Caregiver unable to participate during session due to:__________________
1. Describe the progress that the child has made toward the IFSP outcomes since thelast session. Include parent/caregiver feedback.
1. Describe the progress that the child has made toward the IFSP outcomes since thelast session. Include parent/caregiver feedback.
2. IFSP Functional Outcome(s) and Objective(s) addressed during this session: 2. IFSP Functional Outcome(s) and Objective(s) addressed during this session:
3. Routine Activities worked on during the session: Activities of Daily Living (ADL) Play/Social Community/Errand Other(s): Strategies used within the Routine Activities: Modeling Cues Prompts Positioning Assistive Technology Other:
3. Routine Activities worked on during the session: Activities of Daily Living (ADL) Play/Social Community/Errand Other(s): Strategies used within the Routine Activities: Modeling Cues Prompts Positioning Assistive Tech Other:
4. How did you coach the parent/caregiver? Observed parent/caregiver and child during routines Parent/caregiver tried activity, feedback exchanged Demonstratedactivity to parent/caregiver Reviewed communication tool with parent/caregiver Other: If the parent/caregiver was unavailable, how did you communicate with them about the session?
4. How did you coach the parent/caregiver? Observed parent/caregiver and child during routines Parent/caregiver tried activity, feedback exchanged Demonstratedactivity to parent/caregiver Reviewed communication tool with parent/caregiver Other: If the parent/caregiver was unavailable, how did you communicate with them about the session?
5. What learning activities did the parent/caregiver agree to do with the child before the next visit:
5. What learning activities did the parent/caregiver agree to do with the child before the next visit:
Parent/Caregiver Signature: _Date: / / Relationship to child:
Parent/Caregiver Signature: _Date: / / Relationship to child:
Interventionist Signature: Date: / / License/Certification #: ___________________________ Sup. Signature (CF, COTA)__________________Lic.# ____________Date: / /
Interventionist Signature: Date: / / License/Certification #: _______________________________Sup. Signature (CF, COTA)__________________Lic.# ____________Date: / /