Face to Face

First Steps Service Provider Face to Face
Child’s Name:
Service Date
Child ID#
Service Start Time
Service End Time
Location of Service

Street Address

City

State & ZipState / Province

Postal / Zip Code
IFSP Outcome to be addressed
Results of Visit
Follow-up Needed
Family Education/involvement
Next Scheduled Session
Time
Location
Please note if there has been any cancelled sessions (and not rescheduled) in between this visit and your last visit
Yes, the provider needed to cancel the session scheduled for
Yes, I (the parent) needed to cancel the last session scheduled for
My signature certifies that the activities identified above occurred at the time and location indicated and that
minutes/hour of direct service were provided to my child/family.
My signature certifies that the activities identified above occurred at the time and location indicated and that minutes/hour of direct service were provided to my child/family.
Parents Signature
Date
Telephone

Area CodePhone Number
Email
Provider Signature
Date
Telephone

Area CodePhone Number
Email
Note: The parent is to be provided with a copy of the completed form.
Should be Empty:

First Steps Service Provider Face to Face