Nyc Early Intervention Program

NYC EARLY INTERVENTION PROGRAM Important Steps, Inc. SESSION NOTE

Child’s Name: ______DOB:______EI#: ______

(Last) (First)

Interventionist’s Name: ______Discipline: _____Location of Service: Home__ Daycare__Facility_ (ind___/group#__)

Date: ___/____/____ Time: From______am/pm To______am/pm Service Type:______Freq/Dur ______Date Note Written: ____/____/____

ICD-9 Code: ______1)CPT Code# ______X___; 2)CPT Code# ______X___; 3) CPT Code# ______X___; 4) 1)CPT Code# ______X___

Make-up for (within 2 weeksfrom missed session): ______ Session cancelled/not held write reason below (indicate make-update): ______

IFSP Outcome(s) Addressed: Reason for cancellation______

Progress by child/family related to outcomes:

Worked with parent/caregiver and child together  Worked with parent/caregiver alone  Worked with child alone

Activity During Session/Child/Family Response:

Activity with parent/caregiver (check all that apply)

 Parent/caregiver tried activity, therapist assisted  Discussed session activity with parent/caregiver Showed parent/caregiver activity

 Collaborated with parent to meet family needs  Reviewed communication tool with parent (calendar, notebook, etc.)

 Parent/Caregiver unable to participate  Parent/caregiver unavailable

List family activity for next week/Carryover activities (What/Where/When):

Services were provided according to the frequency and duration stated in the IFSP.

Parent/Caregiver’s Signature: ______Relationship to child:______

Interventionist’s Signature: ______Credentials/License #______

Supervisor’s Name: ______Supervisor’s Signature: ______Credential/License # ______