(Print Legibly/Use Black Ink Only) Page 1__ of ____

SERVICE TREATMENT LOG .

(Print legibly/use black ink only) Page _1__ of ____ .

Student’s Name (Last, First) / Date of Birth / Service Provider Agency
GEK Therapeutic Resources / Agency NPI #
1083981922 /

District NPI #

Location of Service (as indicated on IEP)

/

Name of Service Provider & NYS License # / ASHA #

/

Therapist NPI #

District /

Name of Supervisor (UDO / USO) & NYS License # / ASHA #

/

Supervisor NPI #

Dates of Service (as indicated in IEP) │ Rx Date / Service Type | Group Size │Session per wk x min (per IEP) | ICD-10 Code
G
 I
LOCATION OF SERVICE CODES:
S = School, C = Clinic, H = Home, O = Other, specify ______/ SERVICE CODES: P= Service MU= Make Up CA= Child Absent T = Testing
TA= Teacher Absent S= CSE Meeting H= Holiday TM=Team Meeting
NOTE: All Sessions Must Be Signed Off by Someone Witnessing Presence of Service Provider
Session Date: ______
CPT Code: ______
Start Time: ______
End Time:______
Session Code:______
Actual # in Group: _____
Location Code: ______ / ACTIVITY______
RESPONSE:______
______
______
PROGRESS (CHECK ONE): Progress Limited Progress No Progress Regression
Verifying Witness Signature ______
ProviderSignature, Title, Lic# ______
SupervisorSignature, Title, Lic #______
Session Date: ______
CPT Code: ______
Start Time: ______
End Time:______
Session Code:______
Actual # in Group: _____
Location Code: ______ / ACTIVITY______
RESPONSE:______
______
______
PROGRESS (CHECK ONE): Progress Limited Progress No Progress Regression
Verifying Witness Signature ______
ProviderSignature, Title, Lic# ______
SupervisorSignature, Title, Lic #______
Session Date: ______
CPT Code: ______
Start Time: ______
End Time:______
Session Code:______
Actual # in Group: _____
Location Code: ______ / ACTIVITY______
RESPONSE:______
______
______
PROGRESS (CHECK ONE): Progress Limited Progress No Progress Regression
Verifying Witness Signature ______
ProviderSignature, Title, Lic# ______
SupervisorSignature, Title, Lic #______
Session Date: ______
CPT Code: ______
Start Time: ______
End Time:______
Session Code:______
Actual # in Group: _____
Location Code: ______ / ACTIVITY______
RESPONSE:______
______
______
PROGRESS (CHECK ONE): Progress Limited Progress No Progress Regression
Verifying Witness Signature ______
ProviderSignature, Title, Lic# ______
SupervisorSignature, Title, Lic #______
I certify that this is a true and accurate representation of the services provided and I am aware of the penalties for filing false statements.

S E R V I C E T RE A T M E N T L O G

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Student’s Name (Last, First):______DOB:______Service Type: ______

Provider Name:______

LOCATION OF SERVICE CODES:
S = School, C = Clinic, H = Home, O = Other, specify ______/ SERVICE CODES: P= Service MU= Make Up CA= Child Absent T = Testing
TA= Teacher Absent S = CSE Meeting H = Holiday TM=Team Meeting
NOTE: All Sessions Must Be Signed Off by Someone Witnessing Presence of Service Provider .
Session Date: ______
CPT Code: ______
Start Time: ______
End Time:______
Session Code:______
Actual # in Group: _____
Location Code: ______ / ACTIVITY______
RESPONSE:______
______
______
PROGRESS (CHECK ONE): Progress Limited Progress No Progress Regression
Verifying Witness Signature ______
ProviderSignature, Title, Lic# ______
SupervisorSignature, Title, Lic #______
Session Date: ______
CPT Code: ______
Start Time: ______
End Time:______
Session Code:______
Actual # in Group: _____
Location Code: ______ / ACTIVITY______
RESPONSE:______
______
______
PROGRESS (CHECK ONE): Progress Limited Progress No Progress Regression
Verifying Witness Signature ______
ProviderSignature, Title, Lic# ______
SupervisorSignature, Title, Lic #______
Session Date: ______
CPT Code: ______
Start Time: ______
End Time:______
Session Code:______
Actual # in Group: _____
Location Code: ______ / ACTIVITY______
RESPONSE:______
______
______
PROGRESS (CHECK ONE): Progress Limited Progress No Progress Regression
Verifying Witness Signature ______
ProviderSignature, Title, Lic# ______
SupervisorSignature, Title, Lic #______
Session Date: ______
CPT Code: ______
Start Time: ______
End Time:______
Session Code:______
Actual # in Group: _____
Location Code: ______ / ACTIVITY______
RESPONSE:______
______
______
PROGRESS (CHECK ONE): Progress Limited Progress No Progress Regression
Verifying Witness Signature ______
ProviderSignature, Title, Lic# ______
SupervisorSignature, Title, Lic #______
I certify that this is a true and accurate representation of the services provided and I am aware of the penalties for filing false statements.