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Embed code for: JST Session Note 10-1-15 
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Child’s Name: DOB: / / Sex: M F IFSP Exp Date: Authorization# Basic Ext
Provider Name: Victoria Pavloivc Credentials MSCCC-SL NPI #: 1619038387 Service Type: speech Referring Provider NPI#
Session Date: ____/____/____ IFSP Service Location: _____________________
Time: From _______________ AM PM To __________________ AM PM
ICD code: _____________ CPT Codes:92507x3
ICD code: _____________ CPT Codes: 92507 x_3
Session cancelled–(list reason in #1 below) Co-visit (w/whom)________________
This is a make-up for a missed session on ___/___/______
Session Participants: child parent/caregiver Other: ___________
Parent/Caregiver unable to participate during session due to:____________________
Parent/Caregiver Signature: ___________________________Date: ___/___/______
Relationship to child:
1. Describe the progress that the child has made toward the IFSP outcomes since the last session. Include parent/caregiver feedback.
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 coach 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
4. How did you coach 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 learning activities did the parent/caregiver agree to do with the child before the next visit:
Provider Signature: _______________________________Date: ____/____/____
Jump Start Therapy
Child ID #__________________ NYEIS ____ KIDS____ Agency NPI # 1790092310