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Family ID#

By Ralph Campbell,2014-08-12 09:45
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Family ID# ...

    FAMILY SCHOOL CONNECTION

    HOME VISIT RECORD

    Family ID#: ___________________ HV: _____________________________

    Check all that apply and explain concerns in progress notes

    Type of Visit: ; HV ; Office ; Joint visit w/ Supervisor

    ; Other: ___________ Length of Visit: __________________________

1. Who was Present: ; Mother ; Father ; Baby ; Siblings ; MGF

     ; PGM ; MGM ; PGF ; Other: ____________________

2. Status of Home: ; Bright ; Clean

    ; Messy ; Organized

    ; Safe ; Crowded

    ; Toys Available ; Food/formula

    ; Baby supplies ; Reading Material Available

    ; Utilities off/phone/heat ; Other

    3. Status of Mother: ; Healthy ; Sick ; Withdrawn

     ; Alert/Active ; Sleepy ; Tearful

    ; Clean ; Unkempt ; Friendly

    ; Resistant ; Talkative ; Other

    3. Status of Father: ; Healthy ; Sick ; Withdrawn

     ; Alert/Active ; Sleepy ; Tearful

    ; Clean ; Unkempt ; Friendly

    ; Resistant ; Talkative ; Other

    4. Status of Child: ; Healthy ; Sick ; Alert

     ; Active ; Lethargic ; Fussy

     ; Playful ; Quiet ; Clean

     ; Dressed Appropriate ; Sleeping ; Crying

    ; Other

    5. Child’s medical care:

     a. Well child Date of last well child care appt: ____/_____/____ Kept ? ;

     Next well child care appt. _____/_____/_______

    b. Immunizations: Up To Date? ; Yes ; No

    c. Sick Child Care: ;ER ;Walk-In ;MD Date:____/____/____ Reason:

    d. Dentist Date of last well child care appt: ____/_____/____ Kept ? ;

     Next dentist appt. _____/_____/_______

6. Child's education: Academic Progress ; ? Grade Level ; Grade Level ; ? Grade Level

     Behavior Progress ; ? Average ; Average ; ? Average

     Tardiness/Attendance ; Increase ; Same ; Decrease

     IEP/PPT ; Discussed ; Revised ; NA

7. Significant Relationships Discussed:

     ; Father of Child ; Boyfriend

    ; Other family members ; Other significant adults/peers

8. Parent/Child Interaction:

     ; Responded to Child’s Cues ; Held/Touched Child

     ; Good Eye Contact ; Empathetic

    ; Has an Understanding of Appropriate Expectations ; Other ____________

    70435348.doc Page 1 of 3 Confidential Information

    FAMILY SCHOOL CONNECTION

    HOME VISIT RECORD

    9. NFP & FDP: ; Discussed ; Revised ; Revised

     Due to Crisis

    Competency Area/Parenting Construct: _____________________________________________

    Topic: _______________________________________________________________________

    Met Knowledge and Practice Measurement: ; Yes ; No

    Gains:

    _____________________________________________________________________________________________

    Obstacles:

    _____________________________________________________________________________________________

11. Evaluation: ;Baseline ;HOME ; CLS ; PSI

    ; Parent/Involvement Survey

12. Resources:

    a. Parent(s) provided with education about family learning opportunities? Yes ; No ;

     b. Parent(s) provided with information about school events/activities? Yes ; No ;

     c. Parent(s) provided with information about community resources? Yes ; No ;

     d. Community referral made? Yes ; No ;

     Where, When and Who: ________________________________________________________________________

     ____________________________________________________________________________________________

Progress Notes: Please share any pertinent information about issues, accomplishments, setbacks, significant social events, including

    descriptive and relevant data about the activities undertaken with the family.

    70435348.doc Page 2 of 3 Confidential Information

    FAMILY SCHOOL CONNECTION

    HOME VISIT RECORD

Progress Notes cont.

Plans for Next Visit/Follow-up

    HV Signature: ________________________________________________ Date of Next Visit: ________/________/________

    Clinical Supervisor Signature: ________________________________________ Date Reviewed: ______/______/_____

    70435348.doc Page 3 of 3 Confidential Information

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