Early Intervention Progress Form PDF Details

The early intervention progress form is a document that tracks the progress of a child who is receiving early intervention services. This document is used to evaluate the effectiveness of services and to make changes as needed. The progress form should be filled out by the parents or guardians of the child, as well as by professionals who are working with the child. It can be helpful to keep track of milestones reached by the child, as well as any concerns or problems that have been observed. The form can also be used to track the child's development over time.

QuestionAnswer
Form NameEarly Intervention Progress Form
Form Length5 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 15 sec
Other namesnyc early intervention program, early intervention session note, nyc early intervention progress report template, sample ei progress report

Form Preview Example

NYC Early Intervention Program Session Note

Child’s Name: __________________________________DOB: _____/_____/______ Sex: Male Female

EI #: __________________________

Interventionist’s Name: ___________________________________Credentials: ______________________

National Provider ID #: ___________________________ Service Type: ____________________________

Session Date: ____/____/____ IFSP Service Location: ________________________ Date Note Written: ____/____/____

Time: 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: _________

Session cancelled - reason listed in #1. Session must be made up by: ____/____/____

This is a make-up for a missed session on ____/____/____. (must be within 2 weeks)

Session Participants: child parent/caregiver Other: ____________________________________________________

If the parent/caregiver was unavailable, how did you communicate with them about the session?

1.Describe the progress that the child has made toward the IFSP outcomes since the last session. Include parent/caregiver feedback.

Additional information about the session (as appropriate):

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:___________________________________________________________________________________________

4.How did you work with the parent/caregiver? Observed parent/caregiver and child during routines Parent/caregiver tried activity, feedback exchanged Demonstrated activity to parent/caregiver Reviewed communication tool with parent/caregiver Other:________________________________________________

5.What strategies/activities did you and the parent/caregiver collaboratively agree to do to support their child’s learning and development between visits?

Parent/Caregiver Signature: _________________________________________________________Date: ____/____/____

Relationship to child: ________________________________________________________________________________

Interventionist Signature: ___________________________________________________________Date: ____/____/____

License/Certification #:_______________________________________________________________________________

NYC Early Intervention Program Session Note 9/2015 Version 2 – One Session Note Per Page

NYC EARLY INTERVENTION PROGRAM

INSTRUCTIONS FOR COMPLETION

SESSION NOTES

GENERAL DIRECTIONS

The interventionist must complete this form for each session completed and document whenever a session is cancelled and the reason for the cancellation on the form. The family should receive a copy of the session note as close as possible to the completed session. A copy must also be submitted to the interventionist’s provider agency for billing purposes. All Session Note fields are mandatory. A provider may add additional fields to the form if necessary. Refer to the Session Note Policy

 

DEMOGRAPHIC/AUTHORIZATION INFORMATION

Child’s Name:

Information must be the same as in NYEIS (do not use nickname).

DOB:

Enter child’s date of birth.

Sex:

Enter the sex of the child (M, F)

EI #:

The EI # appears at the top of the “Child Homepage” in NYEIS

Interventionist Name:

Print the name of the interventionist who is completing this form.

Credentials:

Interventionist’s discipline/credentials, e.g. speech therapist (Speech/Language Pathologist, MS,

 

CCC/SP, special educator (MS Ed.), etc.

National Provider ID (NPI):

Write the National Provider ID (NPI). [See NY State regulations from June 2010.]

Service Type:

IFSP authorized service delivered by the interventionist, e.g. Speech, Physical Therapy

Session Date

Date session was held.

IFSP Service Location:

This is the location the IFSP indicates the service is to be provided (i.e., facility, etc.).

Date note written:

Date that the interventionist completes the note. It is expected that notes are written

 

contemporaneously or as close as possible to the session.

Time:

Exact duration of session. From begin time to end time. AM/PM must be indicated in order to

 

support billing.

ICD-10 code*

The relevant ICD-10 code as indicated on the child’s evaluation (effective 10/1/2015).

HCPCS Code (if applicable)

Enter the Level II HCPCS code for the service or product provided by a non-health care

 

interventionist (for example, Special Educator).

CPT Code(s)

Enter the CPT code(s) as indicated by the interventionist’s professional association.

 

Depending on the CPT code, a session may require that more than one. For example, if

 

the same service was provided for a 30 minute session and the CPT code is for 15

 

minutes of service, the CPT code would be listed twice. (See Early Intervention

 

Memorandum 2003-1).

Session Cancelled:

When a session is cancelled:

 

1. Indicate that the session was cancelled and document the reason under question #1.

 

2. The missed session must be made up before: Write the date that is 2 weeks from the

 

missed session. The make-up session should occur prior to this date.

 

3. This is a make-up session for: If this session is a make-up session, check this box and

 

indicate the date of the missed session.

 

Note: Refer to the Make-Up Policy

 

 

Session Participants

Check the box that indicates the session participants. Specify others not listed (e.g., siblings).

 

 

If the parent/caregiver was

Indicate the method(s) used to communicate strategies to the parent/caregiver when they are not

unavailable, how did you

available. Consistent communication and collaboration with families and with the EI team are

communicate with them

essential in early intervention services.

about the session?

Communication with the family and other EI professionals is important for teaming and

 

collaboration. Document briefly the strategies that were used to work with the child

 

when the parent/caregiver was not available or chose not to participate in the session.

 

Interventionists may refer to their documentation in questions #3 and #5 when this is the

 

information they communicated.

 

Parents decide how they want to communicate with their EI team whether they are

 

receiving services at home, at a center-based program, at a facility, and at a day care

 

center. Different types of methods include a communication book, videos, phone calls,

 

the voluntary NYC EIP Family Activity Sheet, etc. If parents want to use emails, please

 

see the NYS DOH BEI Policy and Parent Consent to use emails.

*Visit https://support.eibilling.com/Main/Default.aspx for detailed guidance on ICD-9 to ICD-10 conversation.

NYC Early Intervention Session Note Instructions 9/2015

Questions #1 to #5 support the interventionist in their work with the parent/caregiver and the child. Below is a diagram to visually show what kind of information is to be covered. (Refer to the Appendix for definitions of terms.)

 

Coach parent

 

 

on strategies

 

Observation

that fit the

 

child and

 

of child &

Feedback

family best.

parent in

 

from parent

routine

 

 

activities

 

 

 

Learning

Agree and

 

review

 

Activities to

Functional

strategies

do until the

Outcomes

within the

next visit

 

routine

 

 

activities

 

 

The information in this section guides what will be worked on during the current session.

1.

Describe the

In this section, the interventionist must document:

 

progress/responses that

1. The progress the child has made since the last visit (e.g., generalization to other routines,

 

the child has made toward

ease of doing, obstacles encountered) after observing the child and parent/caregiver in the

 

the IFSP outcomes since

routine and discussing it with the parent/caregiver.

 

the last session. Include

 

2. Document feedback from the parent/caregiver as to what strategies worked and did not

 

parent/caregiver feedback.

 

work.

 

 

 

 

Document any other information about activities that took place during the session. This may

Additional information about

include the following:

the session (as appropriate)

Updated information about the child/family if there are changes in medical or developmental

 

 

status or in community services; indication of whether parent/caregiver is interested in attempting

 

 

new functional outcomes or strategies.

 

 

Any other information about the session the interventionist wants to record.

2.

IFSP Functional

Document the IFSP functional outcome(s) and objective(s) that was worked on in this session

 

Outcome(s) and

with the child and parent/caregiver.

 

Objective(s) addressed

Interventionists should address the IFSP functional outcomes and objectives based on

 

during this session:

their own scope of practice proficiency, knowledge and experience.

 

 

Whenever interventionists believe that they cannot address an IFSP functional outcome

 

 

or objective, they should document this in Question #1 in the NYC EIP Progress Note

 

 

with an explanation.

 

 

Note: Ongoing discussion with the parent/caregivers about what their concerns, priorities and

 

 

resources currently are will help guide the functional outcome or objective that will be worked on

 

 

during the sessions and promote collaboration with families.

3.

Routine Activities worked

The session note must include documentation that services are being delivered within the context

 

on during the session:

of the family’s natural routines and are functional for the child.

 

 

1. The routines must be specific to the family’s cultural and social environment and are of a

 

 

concern and priority for them.

 

 

2. The routine activities should include but are not limited to those listed in the functional

 

 

outcomes in the IFSP.

 

 

3. It is expected that a range of family routines be documented when appropriate. Routines

 

 

should not be limited to “play routines”.

 

 

Check off all those routine activities that were used during the session, or write in the daily

 

 

routine if it is not listed. Routine activities may include:

 

 

Activities of Daily Living (ADL) Routines which cover hygiene routines, food

 

 

 

routines, and dressing routines;

 

 

Play/Socialization routines,

 

 

Community/Family routines;

NYC Early Intervention Session Note Instructions 9/2015

 

Song/Rhyme Routines; and

 

Book Routines.

 

Note: Interventionists should work collaboratively with family to seek opportunities to adapt

 

learning experiences and therapeutic strategies to reflect the individual characteristics of the child

 

and family, and to identify and implement, as appropriate, strategies that enhance and promote the

 

child’s participation in natural learning opportunities across both child and family routines and

 

community settings [ (NYS DOH Provider Agreement XII C4).

 

Indicate which strategies were used to help the families/caregivers successfully support

 

their children’s participation in daily activities.

Strategies used within the

The following are examples of strategies:

Routine Activities:

Positive reinforcement at all levels;

Parent models, child imitates;

 

 

Verbal cues only;

 

Gesture with verbal cues;

 

Physical prompts;

 

Hand-over-hand;

 

Increased opportunities to practice;

 

Modification of the social or the physical environment;

 

Positioning;

 

Adaptation of materials;

 

Use of Assistive Technology; and

 

Discrete trial instruction.

4. How did you work with

Each family learns in different ways. Some families may not choose to participate in a session

the parent/caregiver?

while others may choose to participate. Check off all techniques used during the session. If a

 

technique was used that is not listed, please check “other” and describe the technique(s).

 

Some techniques that can be utilized with the parent/caregiver include, but are not limited to:

 

Observed parent/caregiver and child performing activities;

 

Discussed activity with parent/caregiver;

 

Assisted parent/caregiver;

 

Gave the parent/caregiver a picture illustrating the way to position the child after

 

 

demonstrating the method;

 

Demonstrated parent/caregiver-child activity while describing and explaining what

 

 

was happening;

 

Modeled and explained a strategy and provided feedback as parent/caregiver tried

 

 

the activity with the child;

 

Videotaped learning activity and reviewed with parent/caregiver;

 

Observed parent/caregiver and child performing activities, with both the

 

 

parent/caregiver and the interventionist providing feedback during the session;

 

Reviewed communication tool with parent/caregiver;

 

Identified the methods and sequence of an activity for the parent/caregiver; and

 

Generalized the strategy to other routines with the parent/caregiver.

 

 

5. What strategies/activities

Outline the strategies/activities that the parent/caregiver has agreed to do until the next visit.

did you and the

Indicate here if the parent/caregiver did not agree to work on a strategy/activity with the reason (if

parent/caregiver

given).

 

collaboratively agree to do

 

 

to support their child’s

During each visit, the interventionist and the parent/caregiver can determine and collaborate

learning and development

together on which learning activities:

between visits?

Will be integrated into the child and family’s natural routines, based on family’s comfort

 

level.

 

Will be used to build upon the child and family’s strengths and competencies.

 

Can be used by the family without the presence of the interventionist.

 

Include the following information, if applicable:

 

If the child is authorized for an AT device, describe how the family will use the device as

 

part of the child’s daily routine.

 

Support the generalization of the child’s new skills and abilities. Describe the

 

framework of the strategies and whether they may be used in other natural routines when

 

the child and family feel they have been successful.

 

Include recommendations made by other interventionists working with the

NYC Early Intervention Session Note Instructions 9/2015

 

parent/caregiver and child whenever possible.

 

 

Parent/caregiver signature

At the end of the session, the parent/caregiver who participated in the session signs the session

and relationship to the child:

note and indicates his/her relationship to the child. The date written on the note is the date that the

 

parent signs the completed note. A parent must never be asked to sign an incomplete, blank,

 

or undated note.

 

*This does not apply for facility-based or group developmental services.

Interventionist signature,

The interventionist signs the session note and adds his/her credentials. If certified, write

credentials, date and

“certified” and do not indicate number. The date that the session note was created, and signed by

license/certification number:

the parent, is then entered.

 

For sessions with student interns, CFYs, OTAs, and PTAs, this field may also include the

 

signature and license/certification number of a supervisor, as applicable. A date should also be

 

indicated.

Procedural Notes:

A Family Activity Sheet is available to help support the parent/caregiver in the learning activities until the next session (it follows the session note in this chapter of the NYC Policy and Procedure Manual, and is also available on the www.nyc.gov website).

The Family Activity Sheet is a voluntary tool that can be used to document the strategies that the family plans to use during targeted daily routines. The type of tool that the parent/caregiver decides to use is individual to the family. They may decide to use either the Family Activity Sheet, or a communication notebook, or a calendar or even a combination of these tools. They may also use different tools at different times, or decide not to use any tool.

NYC Early Intervention Session Note Instructions 9/2015

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