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	Start Time	End Time	Total Time	Service Type	Treatment Key	Individual or Group	Progress Indicator Key	Daily Progress Note

Service Type
Progress Indicator Key
D- Direct Session

DM- Direct Session: Make-up Session
MN- Maintaining

RG- Regressing

PR- Progressing	MS- Mastering

IN- Inconsistent

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

Treatment Key:	Page 2 of 2

1	Direct	Examining a student’s history, mental status, or behavior.
2	Direct	Communicating with the student, family, service providers, educators, and others.
3	Direct	Ordering and interpreting laboratory tests and other diagnostic studies.
4	Direct	Pharmacological management of psychotropic medications.
5	Direct	Conducting individual psychotherapy.
6	Direct	Crisis Assistance.
7	Direct	Developing an Individual Behavior Plan providing specific instructions for PCAs, teachers, and other support staff working with a mental health disabled student.

Psychiatric Services Log

www.leaderservices.com/pa ( sbap@leaderservices.com ( SBAP-Align support: (800) 360-8511
© 2013 Leader Services [PA0413]

Psychiatric Professional Services Log

Leader Services

2013-04-22

fbloss

Leader Services

Leader Services