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July 4, 2019

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Session Notes

Date *

(mm/dd/yyyy)

Name (Client initials) *

Time in *

Time out *

Total Time *

(__hrs., ___min.)

Therapist Name

Did you recieve supervision during this appointment *

yes
no

If yes, how much?

__hrs., ___min.

Address

People Present during session *

This address is

Home
Community
School
Residential Setting
Other

Patient condition upon arrival

No sign of illness
Fatique
Cold
Fever
Other

Session Narrative *

Communication Goals

Behavior Goals

Response to Treatment

Name *

First

Last

Did the parents participate in the session?

Yes, mom only
Yes, dad only
yes, mom and dad
No, neither

Procedures attempted during session

Positive Reinforcement
Differential Reinforcement
Visual Schedules
Activity Schedules
FCT
Extinction
Task Analysis

Multiple Choice

First Choice
Second Choice
Third Choice

Multiple Choice

First Choice
Second Choice
Third Choice

Multiple Choice

First Choice
Second Choice
Third Choice

Signature *

First

Middle

Last

Date *

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