Clinical Console/Daily Session Note

Daily Session Note

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Session Documentation: Maya Patel

Care Team: Suzanne Gould, MCD, CCC-SLP • NLA Stage 4 • ASI Sensory Profile

S: Subjective & Polyvagal Arousal State
O: Objective STO Scoring & Rapid Prompt Counters1-Tap Counter Controls

1. Child will mitigate 2 existing whole scripts into novel 2-unit combinations (e.g., "Lets go" + "outside", "Look at" + "the bubbles") during interactive sensory play.

75% Success
Trials:
6 / 8

2. Child will select high-frequency core words (e.g., "Go", "Stop", "More", "Help") on high-tech AAC to direct co-regulatory motor activities.

75% Success
Trials:
6 / 8

3. Child will complete motor planning ideation and bilateral coordination across suspended bolster swing to crash pad with graded force.

75% Success
Trials:
6 / 8

4. Child will recognize body state changes (fast breathing, muscle tension) and request a self-soothing sensory accommodation (weighted blanket, quiet tent).

75% Success
Trials:
6 / 8
A: Clinical Assessment
P: Plan & Scaffolding Next Session
Billing CPT Codes:
Auto-Generated Parent Digest

Real-time translation from raw clinical SOAP into an empowering, non-clinical summary for Elena.

Caregiver Narrative

Maya had a wonderful co-treatment session! We focused on supporting Maya's natural curiosity and communication flow. During our activities, Maya achieved outstanding engagement consistency.

🌟 Celebration Moment

Maya independently used new word combinations to ask for the swing and cheered with huge smiles when the block tower tumbled down!

🏡 Daily Home Carryover Task

Bedtime "Ready, Set... Action!" Play

Pause before turning pages during bedtime stories to invite Maya to initiate with gestures, words, or AAC device!