7.9.2aYOUTH CONSULTATION SERVICE

Description of Client Visit with Parent/Caregiver

Parent/Caregiver Name: ______Date: ______

Client: ______Time: ______

(Check the Type of Visit)

DayPass - how many hours off-site? ______ Overnight - how many nights off-site? ______

(Ask the Parent/Caregiver if applicable)

1. How was the overall visit? ______

2. What were activities you did?At home ______outside______

Special trip or family event______

Yes,
Definitely / Yes,
Probably / Not
Sure / Probably
Not /

Definitely

Not

3. Was he/she generally cooperative during activities?

______

4. How did he/she get along with you and other adults in the home or at activities ______

With siblings and other children______

5. How would you describehis/her general mood ______

6. Were there any behavior issues? Yes or No If “Yes”, what and during what time?

______

7. If the child was out of control, how did you handle the situation, to try to get them to calm down? ______

8. Did he/she voice any concerns during your time together? ______

Yes

/

Somewhat

/
No

9. Did he/she eat well while with you?

Yes

/

Somewhat

/
No

10. Did you have any other concerns regarding

mealtime?

Yes

/

Somewhat

/
No

11. Washe/she cooperative with bedtime?

Yes

/

Somewhat

/
No

12. Did he/she sleep well through the night?

13. How do you feel your child’s behavior hasimproved since your last visit?

Much
Better / A Little
Better / About
the Same / A Little Worse /

Much

Worse

14. What changes would you make to further improve the child’s behavior?

______

15. What concerns do you have?______

16. What would you like help with?______

17. Staff Comments: ______

18. Additional Comments/Suggestions: ______

19: Follow up required by (Check all that apply):

School

Medical

Administration

Reason for follow-up:______

______

Employee Print Name and Signature

RESEARCH:\PIA|CRM\7.9.2aFile this document with progress notes