Session Notes for Truvvy - Date: [Insert Date]

Client Name: Truvvy
Session Duration: [Insert Duration]
Therapist: [Insert Therapist Name]
Location: Playroom and Kitchen

Objective: To observe and document Truvvy's engagement, communication skills, and ability to follow directions during play activities.

Session Summary:

1. Engagement in Activities:

   • Truvvy exhibited active engagement in the playroom and kitchen, demonstrating her ability to communicate needs and preferences effectively.
   • She was observed running back and forth in the playroom, displaying a joyful demeanor with smiles.

2. Communication Skills:

   • When approached by staff at the gate, Truvvy effectively communicated her desire to go outside by grabbing the staff's hand and directing it towards the gate. Staff provided verbal praise for her communication efforts.
   • In the kitchen, staff presented Truvvy with a visual card of her bottle. She successfully grabbed the card and received her bottle, with staff again offering verbal praise.

3. Independent Functioning:

   • Truvvy sat at the table and drank from her bottle independently. After finishing, she transitioned to her room where staff engaged her in play by singing "Twinkle Twinkle Little Star." She actively participated for approximately 10 minutes.

4. Exploration and Interaction:

   • Truvvy moved to the playroom and chose to get into the red wagon. Staff provided a ride for about 15 minutes.
   • When she began to scream, staff stopped the wagon and inquired about her needs. Truvvy communicated by grabbing onto the staff's belt and, after unbuckling, raised her hands to indicate she wanted to get out.

5. Exploration of Environment:

   • After exiting the wagon, Truvvy returned to her room, walking around the clinic and picking up toys, demonstrating exploration and engagement with her environment.

6. Conclusion of Session:

   • At the end of the session, Truvvy independently moved towards the nap room, indicating readiness for rest.

Recommendations:

• Continue to encourage Truvvy's communication through visual aids and verbal praise.
• Monitor her transitions between activities to support her independence and engagement.

Next Steps:

• Plan for further activities that promote communication and exploration in the next session.

Therapist Signature: [Insert Signature]
Date: [Insert Date]