Social Worker Services Log



|Early Intervention |School Age |Page 1 of 2 |

|School Name: |      | |

|Student’s Name: |      |Date of Birth: |      |PA Secure ID |      |Service month/year: |      |

|Provider’s Name: |      |Title: |      |Provider’s Signature: |      |Date: |      |

|Diagnosis/Symptoms: |      |

|Service |Treatment |Progress (Refer to keys below and on page 2 for an explanation on progress indicators and treatment codes) |

|Date |Sta|End Time |

| |rt | |

| |Tim| |

| |e | |

|D- Direct Session | |MN- Maintaining |MS- Mastering |

|DM- Direct Session: Make-up Session | |RG- Regressing |IN- Inconsistent |

| | |PR- Progressing | |

|Supervisor’s Name: | |Supervisor’s Signature: | |Date: | |

|Treatment Key: |Page 2 of 2 |

|2 |Direct |Preparing a social or developmental history of a disabled student |

|3 |Direct |Social Work counseling |

|4 |Direct |Addressing problems in a student’s living arrangements that affect adjustment to and performance in schools |

|5 |Direct |Family counseling to address a student’s needs |

|6 |Direct |Mobilizing school and community resources related to a student’s medical/mental health status to enable maximum benefit from his/her educational program |

|7 |Direct |Crisis Assistance |

|8 |Direct |Social Skill Training |

|9 |Direct |Community-based Training |

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