FAMILY SCHOOL CONNECTION
HOME VISIT RECORD
Family ID#: ______HV: ______
Check all that apply and explain concerns in progress notes
Type of Visit: o HV o Office o Joint visit w/ Supervisor
o Other: ______Length of Visit: ______
1. Who was Present: o Mother o Father o Baby o Siblings o MGF
o PGM o MGM o PGF o Other: ______
2. Status of Home: o Bright o Clean
o Messy o Organized
o Safe o Crowded
o Toys Available o Food/formula
o Baby supplies o Reading Material Available
o Utilities off/phone/heat o Other
3. Status of Mother: o Healthy o Sick o Withdrawn
o Alert/Active o Sleepy o Tearful
o Clean o Unkempt o Friendly
o Resistant o Talkative o Other
3. Status of Father: o Healthy o Sick o Withdrawn
o Alert/Active o Sleepy o Tearful
o Clean o Unkempt o Friendly
o Resistant o Talkative o Other
4. Status of Child: o Healthy o Sick o Alert o Active o Lethargic o Fussy
o Playful o Quiet o Clean o Dressed Appropriate o Sleeping o Crying
o Other
5. Child’s medical care:
a. Well child Date of last well child care appt: ____/_____/____ Kept ? o
Next well child care appt. _____/_____/______
b. Immunizations: Up To Date? o Yes o No
c. Sick Child Care: oER oWalk-In oMD Date:____/____/____ Reason:
d. Dentist Date of last well child care appt: ____/_____/____ Kept ? o
Next dentist appt. _____/_____/______
6. Child's education: Academic Progress o ≥ Grade Level o Grade Level o ≤ Grade Level
Behavior Progress o ≥ Average o Average o ≤ Average
Tardiness/Attendance o Increase o Same o Decrease
IEP/PPT o Discussed o Revised o NA
7. Significant Relationships Discussed:
o Father of Child o Boyfriend
o Other family members o Other significant adults/peers
8. Parent/Child Interaction:
o Responded to Child’s Cues o Held/Touched Child
o Good Eye Contact o Empathetic
o Has an Understanding of Appropriate Expectations o Other ______
9. NFP & FDP: o Discussed o Revised o Revised
Due to Crisis
Competency Area/Parenting Construct: ______
Topic: ______
Met Knowledge and Practice Measurement: o Yes o No
Gains:
______
Obstacles:
______
11. Evaluation: oBaseline oHOME o CLS o PSI
o Parent/Involvement Survey
12. Resources:
a. Parent(s) provided with education about family learning opportunities? Yes o No o
b. Parent(s) provided with information about school events/activities? Yes o No o
c. Parent(s) provided with information about community resources? Yes o No o
d. Community referral made? Yes o No o
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.
Progress Notes cont.Plans for Next Visit/Follow-up
HV Signature: ______Date of Next Visit: ______/______/______
Clinical Supervisor Signature: ______Date Reviewed: ______/______/_____
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