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PRESCHOOL DAILY SESSION NOTES
Child’s Name____________________________________________ DOB_______________________________
Provider Name ____________________________________________Title _______________________________________
Service Provided: _________________________License #_______________ NPI #_______________________
U
nder the Direction Of
Supervisor Name__________________________ License #________________________ NPI #______________________________
*******************************************************************************************************************************
Date: __________________ Time In: ________ Time Out: _________ CPT Code: ________ Units/Sessions________
CPT Code: _______ Units/Sessions_____ CPT Code_____ Units/Sessions_____ ICD-10 Code:__________
Group #:_______ Individual: _____ Location: Classroom_____, Home _____, Head Start _____, Daycare _____, Other _______
Billed______ , Unbilled_________ Brief description of student’s progress:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Therapist Signature & Credentials:____________________________________________________ , Date________________________
Supervisor’s Signature and Credentials:________________________________________________ , Date________________________
*******************************************************************************************************************************
Date: __________________ Time In: ________ Time Out: _________ CPT Code: ________ Units/Sessions________
CPT Code:_______ Units/Sessions_____ CPT Code_____ Units/Sessions_____ ICD-10
Code:__________
Group
#:_______ Individual: _____ Location: Classroom_____, Home _____, Head Start _____, Daycare _____, Other _______
Billed______ , Unbilled_________ B
rief description of student’s progress:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Therapist Signature & Credentials:____________________________________________________ Date, __________________________
Supervisor’s Signature and Credentials:________________________________________________ Date, __________________________
*******************************************************************************************************************************
Date: __________________ Time In: ________ Time Out: _________ CPT Code: ________ Units/Sessions________
CPT Code:_______ Units/Sessions_____ CPT Code_____ Units/Sessions_____ ICD-10
Code:__________
Group
#:_______ Individual: _____ Location: Classroom_____, Home _____, Head Start _____, Daycare _____, Other _______
Billed______ , Unbilled
_________ Brief description of student’s progress:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Therapist Signature & Credentials:____________________________________________________ Date, __________________________
Supervisor’s Signature and Credentials:________________________________________________ Date, __________________________
(Revision 10/18)
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