NASSAU COUNTY DEPARTMENT OF HEALTH
(Print legibly/use black ink only) OFFICE OF CHILDREN WITH SPECIAL NEEDS Page ___ of ___
Preschool Special Education Program
TREATMENT LOG
RELATED SERVICES AND SPECIAL EDUCATION ITINERANT TEACHER (SEIT) SERVICES
Student’s Name (Last, First) DOB: Service Provider/Agency/School School District
Location (Office/Child Care Center/Home/etc) Town of Service Name of Individual Service Provider/License Number
as indicated on IEP
Dates of Service (IEP Dates) Type of Service Name of Individual Supervising Provider/License Number
to
RX Date ICD9 Code:
□ Individual Frequency & Duration as indicated on the IEP
Sessions per week: Minutes:
□ Group
CPT Code: NPI #:
NOTE: All sessions must be signed off by Parent or Authorized SESSION CODES: P-Service MU – Make Up Session CA – Child Absent
COTA, PTA,
Verifying Witness, Provider and UDO/USO Supervisor TSHH, TSSLD,TA- Teacher/Therapist Absent S-CPSE Meeting T-- Testing
or LPN
Date of Session Start Time End Time Session Code Session Notes: Activity/Lesson (Including objectives and CPT Code:
measures of success) and response(s) of child
_______________________________________________________________
Signature of Parent or Verifying Witness Date
_________________________________________________________
Provider Signature/Professional Credentials/License # Date
____________________________________________________
USO/UDO Supervisor Signature Date
Date of Session Start Time End Time Session Code Session Notes: Activity/Lesson (Including objectives and CPT Code:
measures of success) and response(s) of child
_______________________________________________________________
Signature of Parent or Verifying Witness Date
________________________________________________________________
Provider Signature/Professional Credentials/License # Date
____________________________________________________
USO/UDO Supervisor Signature Date
Date of Session Start Time End Time Session Code Session Notes: Activity/Lesson (Including objectives and CPT Code:
measures of success) and response(s) of child
_______________________________________________________________
Signature of Parent or Verifying Witness Date
________________________________________________________________
Provider Signature/Professional Credentials/License # Date
____________________________________________________
USO/UDO Supervisor Signature Date Provider
Date of Session Start Time End Time Session Code Session Notes: Activity/Lesson (Including objectives and CPT Code:
measures of success) and response(s) of child
_______________________________________________________________
Signature of Parent or Verifying Witness Date
________________________________________________________________
Provider Signature/Professional Credentials/License # Date
____________________________________________________
USO/UDO Supervisor Signature Date
Date of Session Start Time End Time Session Code Session Notes: Activity/Lesson (Including objectives and CPT Code:
measures of success) and response(s) of child
_______________________________________________________________
Signature of Parent or Verifying Witness Date
______________________________________________________________
Provider Signature/Professional Credentials/License # Date
____________________________________________________
USO/UDO Supervisor Signature Date
Turn Over For Signature→
Student’s Name (Last, First): ________________________ Page ___ of ___
NOTE: All sessions must be signed off by Parent or Authorized SESSION CODES: P-Service MU – Make Up Session CA – Child Absent
TA- Teacher/Therapist Absent S-CPSE Meeting T-- Testing
Verifying Witness, Provider and UDO/USO Supervisor for TSHH, TSSLD, COTA,
PTA, or LPN
Date of Session Start Time End Time Session Code Session Notes: Activity/Lesson (Including objectives and CPT Code:
measures of success) and response(s) of child
_______________________________________________________________
Signature of Parent or Verifying Witness Date
_________________________________________________________
Provider Signature/Professional Credentials/License # Date
____________________________________________________
USO/UDO Supervisor Signature Date
Date of Session Start Time End Time Session Code Session Notes: Activity/Lesson (Including objectives and CPT Code:
measures of success) and response(s) of child
_______________________________________________________________
Signature of Parent or Verifying Witness Date
_______________________________________________________________
Provider Signature/Professional Credentials/License # Date
____________________________________________________
USO/UDO Supervisor Signature Date
Date of Session Start Time End Time Session Code Session Notes: Activity/Lesson (Including objectives and CPT Code:
measures of success) and response(s) of child
_______________________________________________________________
Signature of Parent or Verifying Witness Date
________________________________________________________________
Provider Signature/Professional Credentials/License # Date
____________________________________________________
USO/UDO Supervisor Signature Date
Date of Session Start Time End Time Session Code Session Notes: Activity/Lesson (Including objectives and CPT Code:
measures of success) and response(s) of child
_______________________________________________________________
Signature of Parent or Verifying Witness Date
________________________________________________________________
Provider Signature/Professional Credentials/License # Date
____________________________________________________
USO/UDO Supervisor Signature Date
Date of Session Start Time End Time Session Code Session Notes: Activity/Lesson (Including objectives and CPT Code:
measures of success) and response(s) of child
_______________________________________________________________
Signature of Parent or Verifying Witness Date
______________________________________________________________
Provider Signature/Professional Credentials/License # Date
____________________________________________________
USO/UDO Supervisor Signature Date
Contact and Comments Codes: TC – Telephone Conference CN – Communication Notebook CO -- Coordination
R – Weekly Recommendations/Interventions for Classroom Teacher/Caregiver O – Other
Date Codes Notes
I certify all information entered on this Treatment Log is correct (Provider Sig.) _______________________________________________
Date_________/________/_______
Treatment Log Reviewed by ______________________________________________ Date_________/________/_______
PS 1100Trearment Log 6-28-2010