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Note-Westchester... · Web viewHow did you coach the parent/caregiver? Observed parent/caregiver and child during routines Parent/caregiver tried activity, feedback exchanged

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Page 1: Note-Westchester... · Web viewHow did you coach the parent/caregiver? Observed parent/caregiver and child during routines Parent/caregiver tried activity, feedback exchanged

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: / /