Child’s Name: Ambar DOB: Sex: ☐ Male X Female EI #: 110011011101

Interventionist’s Name: Carolina Flechas Castro Credentials: CF/SLP applicant National Provider ID #: 111111 Service Type: ST
Session Date: 03_/_16_/2023 IFSP Service Location: ____Home____________ Session Date: ____/____/____IFSP Service Location: ___________________________
Time: From _____10:30_____ X AM  PM To _____11___X AM  PM Time: From _______________  AM  PM To __________________ AM  PM
Date Note Written: 03_/_16_/2023 ICD-10 code: F 80.2 Date Note Written: ____/____/____ ICD-10 code:
HCPCS Code (if applicable):____________________ 1st CPT Code: 92507______ HCPCS Code (if applicable):____________________ 1st CPT Code: ______________
2nd CPT Code: _________ 3rd CPT Code: __________ 4th CPT Code: _________ 2nd CPT Code: _________ 3rd CPT Code: __________ 4th CPT Code: _________
Session cancelled - reason listed in #1. Session must be made up by: ____/____/____ 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) This is a make-up for a missed session on ____/____/____.(must be within 2 weeks)
Session Participants: X child X parent/caregiver Other: _______________________ Session Participants: child parent/caregiver Other: _______________________
If the parent/caregiver was unavailable, how did you communicate with them about the If the parent/caregiver was unavailable, how did you communicate with them about the
session? N/A session?
1. Describe the progress that the child has made toward the IFSP outcomes since the 1. Describe the progress that the child has made toward the IFSP outcomes since the
last session. Include parent/caregiver feedback. First session with Ambar, at her home. last session. Include parent/caregiver feedback.
The mother reported that Ambar doesn´t answer her name when called, she cries a lot
and stop crying when things catch up to her. The mother would like that Amber
respond to her name and says words to communicate her needs.
Additional information about the session (as appropriate): Amber was active and Additional information about the session (as appropriate
attentive during session. Ambar recognized and produce sounds when listen her name,
amber points objects and things she wants, also, she reaches for an close object to the
therapist's request with verbal cues and imitation
2. IFSP Functional Outcome(s) and Objective(s) addressed during this session: 2. IFSP Functional Outcome(s) and Objective(s) addressed during this session:
Ambar will use communicative gestures.
Ambar will respond to her name.
3. Routine Activities worked on during the session: X Activities of Daily Living (ADL) 3. Routine Activities worked on during the session:  Activities of Daily Living (ADL)
X Play/Social  Community/Errand  Other(s):______________________________  Play/Social  Community/Errand  Other(s):______________________________
Strategies used within the Routine Activities: X Modeling X Cues  Prompts Strategies used within the Routine Activities:  Modeling  Cues  Prompts
 Positioning  Assistive Technology  Other: Imitation, verbal and visual cues  Positioning  Assistive Tech  Other:
4. How did you coach the parent/caregiver? X Observed parent/caregiver and child 4. How did you coach the parent/caregiver? Observed parent/caregiver and child
during routines X Parent/caregiver tried activity, feedback exchanged X Demonstrated during routines  Parent/caregiver tried activity, feedback exchanged Demonstrated
activity to parent/caregiver  Reviewed communication tool with parent/caregiver X activity to parent/caregiver Reviewed communication tool with parent/caregiver
Other:__ Discussed activity with mother______________________  Other:_______________________________________________________________

5. What strategies/activities did you and the parent/caregiver collaboratively agree to do 5. What strategies/activities did you and the parent/caregiver collaboratively agree to do
to support their child’s learning and development between visits? to support their child’s learning and development between visits?
Provider has recommended to Amber´s mother will touch her arm when calling her by
her name to help her to respond to her name consistently

Parent/Caregiver Signature: _Ana _____________Date: _03_/_16_/2023 Parent/Caregiver Signature: ______________________________Date: ____/____/____

Relationship to child: Mother____________________________________________ Relationship to child: _____________________________________________________
Interventionist Signature: _Carolina Flechas Castro______Date: 03_/_16_/2023 Interventionist Signature: _______________________________Date: ____/____/____
License/Certification #: Supervisor signature License/Certification #:
NYC Early Intervention Program Session Note 9/2015 Version 1 – Two Notes Per Page