Important Steps, Inc. – EI Department

THERAPY MONTHLY LOG Month/Year: ______/______

Child ______EI No.______IFSP Freq___ Dur. ____ Location: Home ___Daycare___

IFSP Therapy Type: __PT __OT __SI __ST __TSHH __SW __FT _Nutr. Other______

Provider Name:______Title/Credentials:______

D
a
t
e
/ Start
Time / End
Time / Session Type:
R= regular
M =makeup
(indicate date of Missed Session) /
D
a
t
e
/ Start
Time / End
Time / Session Type:
R= regular
M =makeup
(indicate date of Missed Session)
1 / am/pm / am/pm / R ÿ / M ÿ __/__/__ / 17 / am/pm / am/pm / R ÿ / M ÿ __/__/__
2 / am/pm / am/pm / R ÿ / M ÿ __/__/__ / 18 / am/pm / am/pm / R ÿ / M ÿ __/__/__
3 / am/pm / am/pm / R ÿ / M ÿ __/__/__ / 19 / am/pm / am/pm / R ÿ / M ÿ __/__/__
4 / am/pm / am/pm / R ÿ / M ÿ __/__/__ / 20 / am/pm / am/pm / R ÿ / M ÿ __/__/__
5 / am/pm / am/pm / R ÿ / M ÿ __/__/__ / 21 / am/pm / am/pm / R ÿ / M ÿ __/__/__
6 / am/pm / am/pm / R ÿ / M ÿ __/__/__ / 22 / am/pm / am/pm / R ÿ / M ÿ __/__/__
7 / am/pm / am/pm / R ÿ / M ÿ __/__/__ / 23 / am/pm / am/pm / R ÿ / M ÿ __/__/__
8 / am/pm / am/pm / R ÿ / M ÿ __/__/__ / 24 / am/pm / am/pm / R ÿ / M ÿ __/__/__
9 / am/pm / am/pm / R ÿ / M ÿ __/__/__ / 25 / am/pm / am/pm / R ÿ / M ÿ __/__/__
10 / am/pm / am/pm / R ÿ / M ÿ __/__/__ / 26 / am/pm / am/pm / R ÿ / M ÿ __/__/__
11 / am/pm / am/pm / R ÿ / M ÿ __/__/__ / 27 / am/pm / am/pm / R ÿ / M ÿ __/__/__
12 / am/pm / am/pm / R ÿ / M ÿ __/__/__ / 28 / am/pm / am/pm / R ÿ / M ÿ __/__/__
13 / am/pm / am/pm / R ÿ / M ÿ __/__/__ / 29 / am/pm / am/pm / R ÿ / M ÿ __/__/__
14 / am/pm / am/pm / R ÿ / M ÿ __/__/__ / 30 / am/pm / am/pm / R ÿ / M ÿ __/__/__
15 / am/pm / am/pm / R ÿ / M ÿ __/__/__ / 31 / am/pm / am/pm / R ÿ / M ÿ __/__/__
16 / am/pm / am/pm / R ÿ / M ÿ __/__/__
Monthly Multidisciplinary Meeting Date:___/___/___
Participants: Name/Title:______
(In narrative form, please describe what was discussed, any issues that have arisen, troubleshooting and problem solving.)
Team Recommendations:

Total Billable Sessions:______

Service Provider’s Signature: ______Date:______

****Session Notes (Originals) Must be Attached and correspond to this Monthly Log