KIDZ THERAPY EARLY INTERVENTION DAILY SESSION NOTES

For services in Nassau County Page 1 of ____

Child’s Name: Date of Birth: / /
IFSP Period: / / to / / Service:______
Type Location Frequency Duration
# Authorized Sessions: Authorization #: ICD-10 Code:
Provider/Agency Name: Provider:
Kidz Therapy Services, PLLC Name Professional Title
Agency NPI #: 1730334426 Provider NPI#

[Key] C= Clinician cancelled CoV = CoVisit FV= Family Vacation H= Holiday I= IFSP meeting

M= Make-up P= Parent cancelled PV= Provider Vacation S= Child sick/hospitalized X= Treatment session

DATE: / / [ ] IN:_____OUT:_____ *Parent/Caregiver Signature:______Date: ______
Desired Outcome/Goals:
Session Content:
*Provider Signature/License Initials: ______Date note written: ______
DATE: / / [ ] IN:_____OUT:_____ *Parent/Caregiver Signature:______Date: ______
Desired Outcome/Goals:
Session Content:
*Provider Signature/License Initials: ______Date note written: ______
DATE: / / [ ] IN:_____OUT:_____ *Parent/Caregiver Signature:______Date: ______
Desired Outcome/Goals:
Session Content:
*Provider Signature/License Initials: ______Date note written: ______
DATE: / / [ ] IN:_____OUT:_____ *Parent/Caregiver Signature:______Date: ______
Desired Outcome/Goals:
Session Content:
*Provider Signature/License Initials: ______Date note written: ______

Recommendations for support, education, and guidance for parents: (Complete )

______

______

______

2015


Child’s Name: Page ____ of ____

DATE: / / [ ] IN:_____OUT:_____ *Parent/Caregiver Signature:______Date: ______ Desired Outcome/Goals:
Session Content:
*Provider Signature/License Initials: ______Date note written: ______
DATE: / / [ ] IN:_____OUT:_____ *Parent/Caregiver Signature:______Date: ______
Desired Outcome/Goals:
Session Content:
*Provider Signature/License Initials: ______Date note written: ______
DATE: / / [ ] IN:_____OUT:_____ *Parent/Caregiver Signature:______Date: ______
Desired Outcome/Goals:
Session Content:
*Provider Signature/License Initials: ______Date note written: ______
DATE: / / [ ] IN:_____OUT:_____ *Parent/Caregiver Signature:______Date: ______
Desired Outcome/Goals:
Session Content:
*Provider Signature/License Initials: ______Date note written: ______

Recommendations for support, education, and guidance for parents: (Complete)

______

______

______

SPECIFIC CONTACT AND COMMENTS BETWEEN TEAM MEMBERS, DOH, AND OTHERS (Doctors, etc.)

DATE / CODES / NOTES

Codes: TC: Telephone Contact AV: Agency Visit HV: Home Visit IFSP: Indiv Fam Svc Plan

TM: Team Meeting CN: Communications Notebook PC: Teacher/Therapist Consult OC: Other Direct Contact

2015