NYC EARLY INTERVENTION PROGRAM - Important Steps



NYC EARLY INTERVENTION PROGRAM SESSION NOTE

Child's Name: DOB: El#: (Last) (First)

Interventionist's Name: Discipline: Location of Service:

Date____/____/_____ Time: From ______am/pm To ______am/pm Service Type: __________ Date note written: _____/______/_____

(MM) (DD) (YY) Frequency/Duration___/___ Make Up For: _____/____/____

IFSP Outcome(s) Addressed:

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:

No Session Provided__Reason:__________________________________________________________________

Parent/Caregiver Signature: Relationship to child:

Interventionist Signature: Credentials/License#:

Date____/____/_____ Time: From ______am/pm To ______am/pm Service Type: __________ Date note written: _____/______/____ MM) (DD) (YY) Frequency/Duration___/___ Make Up For: _____/____/____

IFSP Outcome(s) Addressed:

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:

No Session Provided__Reason:__________________________________________________________________

Parent/Caregiver Signature: Relationship to child:

Interventionist Signature: Credentials/License#:

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Important Steps, Inc.

( Therapist used alternate tool to work with parent/caregiver

(e.g., phone call, notebook)

( Parent/caregiver unavailable

Activity with parent/caregiver (check all that apply)

( Discussed session activity with parent/caregiver

( Showed parent/caregiver activity

( Parent/caregiver tried activity, therapist assisted

( Parent/caregiver unable to participate

List Family Plan/Calendar activity for next week:

( Therapist used alternate tool to work with parent/caregiver

(e.g., phone call, notebook)

( Parent/caregiver unavailable

Activity with parent/caregiver (check all that apply)

( Discussed session activity with parent/caregiver

( Showed parent/caregiver activity

( Parent/caregiver tried activity, therapist assisted

( Parent/caregiver unable to participate

List Family Plan/Calendar activity for next week:

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