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

3	Direct	Psychological evaluation of records for diagnostic purposes
4	Direct	Individual and group therapy
5	Direct	Obtaining, integrating, and interpreting information about medical/mental health conditions in relation to learning
6	Direct	Consulting with a psychiatrist, primary care physician, and other health care professionals to coordinate treatment
7	Direct	Individual and group counseling
8	Direct	Crisis Assistance
9	Direct	Developing and implementing and Individual Behavior Plan providing specific instructions for PCAs, teachers, and other staff working with a mental health disabled student
10	Direct	Skills designed to improve basic functioning of the student in activities of daily and community living and improve social interactions with others.

Psychological Services

www.leaderservices.com/pa ( sbap@leaderservices.com ( SBAP-Align support: (800) 360-8511
© 2013 Leader Services [PA0313]

Psychological Services Log

Leader Services

2013-03-05

fbloss

Leader Services

Leader Services