<p> EARLY HEAD START 2014-2015 HOME VISIT RECORD</p><p>Child’s Name______Age: ______HV #: _____</p><p>Date:______Time: ______Completed FCE Cancel P/G Cancel No Show Make-Up Reschedule date______Time: ______Completed FCE Cancel P/G Cancel No Show Make-Up Reschedule date______Time: ______Completed FCE Cancel P/G Cancel No Show Make-Up</p><p>HOME VISIT PAT Foundational Visit: [ ] F1 [ ] F2 [ ] F3 [ ] F4 [ ] F5 [ ] F6 [ ] F7 </p><p>Planning for Education/Special Needs Services (i.e.: Bright Discussion/Outcomes/Follow-up Futures talking points, developmental concerns, handouts, resource, referral, curriculum used, etc.) </p><p>Portfolio/Milestones Updated? [ ] Yes [ ] No Handouts given/reviewed (circle)?</p><p>Planning for Parenting Education (curriculum/resource used) Discussion/Outcomes/Follow-up □ Healthy Birth □ Attachment □ Discipline □ Health □ Nutrition □ Safety □ Sleep □ Transitions/Routines Key messages:</p><p>Handouts given/reviewed (circle)?</p><p>Planning for Health/Nutrition/Mental Health Services Discussion/Outcomes/Follow-up (i.e.: Dental, WCE, immunizations, healthy meals, budgeting, bonding, relationships, coping with family needs, family changes, Bright Futures talking points, handouts, curriculum used, etc.) Handouts given/reviewed (circle)?</p><p>Planning for Parent Involvement/FPA/Referrals and follow up (Bright Futures talking points related to parent involvement, FPA, identified referrals, newsletters, monthly calendars, Parent Interest Survey, meeting reminders (CPC, PC), community events): </p><p>CURRICULUM - Parent Time Working With The Child and Planning for Home Activities </p><p>Parent/Child Experience/Activity Plan TSG Focused Area/Goal (Check all that apply) Activity: [ ]Social Emotional [ ]Physical [ ]Language [ ]Cognitive [ ]Literacy [ ] Mathematics [ ]Science and Technology [ ]Social Studies [ ]The Arts Curriculum:</p><p>Specific Child’s Goals (within identified area(s)): Materials Needed: FCE observations: What Milestones / Next Steps Parent observations: were observed and discussed? </p><p>What activities will support the child’s goals at home? (Brainstorm with parent and add to In-Kind):</p><p>Family well being factors discussed in this visit (I= shared Information; R= made Referral) □ NONE DISCUSSED □ I □ R Health Insurance, CHIP □ I □ R Child support assistance □ I □ R Medical Home □ I □ R Food and Nutrition Services (food bank, WIC, SNAP) □ I □ R Medical Services □ I □ R Housing and Utilities, subsidies, repairs □ I □ R Tobacco cessation □ I □ R Transportation, drivers license, insurance □ I □ R Dental Services □ I □ R Child care/preschool/HS/EHS, ECEAP □ I □ R Dental Home □ I □ R Disability services -Early intervention, IDEA, Special Ed □ I □ R Substance abuse prevention □ I □ R Domestic violence, support center □ I □ R Substance/drug abuse treatment □ I □ R Assistance to incarcerated individuals □ I □ R Mental Health services □ I □ R Emergency/crisis, disaster needs □ I □ R English Language Classes □ I □ R Immigration application, green card □ I □ R Adult Ed, job training, GED, college prep □ I □ R Child Abuse/Neglect □ I □ R Employment resources (Work source, Career Paths) □ I □ R Recreational/enrichment activities : ______□ I □ R Financial literacy (budgeting, TANF eligibility, □ I □ R Parenting education tax or debt assistance, debt assistance) □ I □ R Health or Safety education □ I □ R Family literacy services (library, literacy activities) □ I □ R Marriage/relationship education □ I □ R Other: ______</p><p>Family Strengths and Barriers Review PAT “Toolkit” (What are they doing to get to the next level?) </p><p>Family Strengths and Protective Factors focused on in this visit: □Parental resilience □ Social Connections □ Knowledge of parenting and Child Development □Concrete support in times of need □Social and emotional competence of children Parent Planning for next visit/Socialization/CPC/ Volunteer/In-Kind Opportunities (volunteer in class, socialization, Workshop (Parent generated ideas for topics, activities, field trips, projects, preparing materials, portfolios/milestones, Parent In-Kind, workshops, dates/times, additional information requested, etc.): etc.):</p><p>Other Discussion (parent comments, suggestions, reminders, upcoming events, progress on goals, etc.):</p><p>Length of visit: ______hours Plan completed? Yes No If no, reason: ______Next visit: Day: ______Date: ______Time: ______</p><p>Documentation (ChildPlus, File, TSG): [ ]HV [ ] Referrals [ ] FPA [ ] Health Info [ ] TSG Obs. [ ] Email Family Members Present: [ ] Mother [ ] Father [ ] Grandmother [ ] Grandfather [ ] Other:______</p><p>Parent signature: ______Date: ______</p><p>Staff signature: ______Date: ______</p><p>Documentation (ChildPlus, File, TSG): [ ]HV [ ] Referrals [ ] FPA [ ] Health Info [ ] TSG Obs. [ ] Email</p>