Healthy Families Cattaraugus Home Visit Record Level ____ Name ...

Healthy Families CattaraugusHome Visit RecordName of Primary Caretaker: ________________________________ Date _____________Level ____Overview:(1) Who was present? ___ Mother ___ FOB ___ Siblings ___ MGM ___ PGM ___ Supervisor ___ TC___ Other (Specify): ______________________________________________________(2) Overall, was home environment appropriate for the child? ___ Yes ___ No. What areas need improvement (e.g. safety,crowded conditions, additional equipment, toys, better cleanliness, etc.)? _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________(3) Focus of parents: ___ on curriculum ___ on IFSP goals ___ on child development ___ other topics related to baby: _______ unable to focus on PCI ___ focus on partner ___ money issues ___ conflicts w/others ___ MOD needs much attention___ unrealistic demands ___ unresponsive ___ overwhelming issues, not allowing focus to be on the child; Explain: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________(4) Status of Baby: __ Appears Healthy __ Clean __ Needs Bath __ Sleeping __ Not at home __ Sick __ Fussy __Alert____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Parent-Child Interaction:(5a) What cues did you observe the baby during the home visit?___ Needing physical attention ___ Needing diaper change ___ Hunger___ Needing playful interaction ___ Repositioning ___ Needing verbal/visual attention___ Avoiding stimulation ___ Needing attention from FOB ___ Other: ______________________________Did parent respond to cues? ___ Yes ___ No. If no, which cues were ignored? _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________(5b) What interaction occurred between MOB and other children? ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________(6) Situations requiring empathy:___ Child was afraid ___ Child was sad ___ Child needed comfort ___ Child needed discipline___ Child needed understanding ___ Other: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________CPS Status: ___ Found ___ Unfounded CPS Close Date: ___________________________ ____N/ADoctor’s Appointments: ___ No ___ Yes; Give date ______ Shots and Check-up this week __________________________

Home Visit RecordFSW Intervention:Overall PCI Intervention (Detail intervention related to PCI assessment): (e.g. indirect/role modeling, praise, education, etc.)____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________What’s new with this parent and/or child this week? (Bonding & attachment; Infant Development; cognitive, fine/grossmotor, language, social/emotional, caring for baby, nutrition, sleeping, health, concerns):____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Mother’s Issues: (Physical changes & discomforts, diet & exercise, alcohol, drugs & medications, smoking, sex & STC’s,family planning, health care, depression, emotional changes). Detail:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Curriculum (Detail topic, supporting activities and family’s response to session):____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________IFSP (Detail discussion and how IFSP was supported by FSW. List goals addressed, involvement of parent, FSW intervention)____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Family Development (Empowerment, Relationship/Support, Planning/Problem Solving, Finances):____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Referrals (What referrals were made to community resources? Why?)____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Follow-up and Concerns: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Plans for next home visit: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Was level change discussed at this home visit? ___ Yes ___ NoComments: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________FSW Signature______________________________________________Supervisor Review