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COURTESY HOME VISIT
Case Name ______Date ______
Case Number ______
CASA Assigned ______
Head of Household ______
Address ______
A. Assessment of Home
1.How long has the family lived there? ______
2.Who lives in the home? What are their names? What relationship are they to the child(ren)?
NAME AGERELATIONSHIP
3.How many bedrooms are there? _____________
4.Does anyone share a room? ______If so, whom?____________
5. How many beds in each room? ______
Does anyone share a bed? ______Ifso,whom?______
______
How old are those sharing a bed?______Are they the same sex? _______ Is (Are) the bed(s);twin, double, queen or king size(s)______
6.Were there clean linens on the beds? _________
7.What other rooms are there in the home? ______
______
8. Are there any rooms that allow the adults privacy? ______
9. Give a general description of the home (apartment, 2 story house, 3 bedrooms, 1 bath, den) ______
10.Were the rooms neat and clean? Elaborate: ____________
______
11.Is the home adequately furnished? ______
12. Was there an adequate amount of food in the home? ______Elaborate:______
13.Were essential items present? (dishes, linens, clothing) ______
14.Were the kitchen and eating areas clean? ______Running water? ______
Was food stored or disposed of properly? ____ Was there any unusual odor?____Elaborate: ______
15.Did the children have adequate and appropriate clothing?___Season appropriate (i.e. winter coats, shorts, jeans) _____ Size appropriate? _____
16Was bathroom clean? ______
Did it have soap, toothpaste, toilet paper and other personal hygiene items? _____
17. Did each child have his/her own toothbrush? ______
18. Were there toys/games present? ______
19.Give general description of the neighborhood (Location, atmosphere, surroundings): ______
______
20. What school/daycare does/will the child(ren) attend? What are their dates of birth?
Child DOB School/Daycare
Is it in the neighborhood? ______If not, explain why? (Children attend a private school, family moved during the middle of the school year. Etc) ______
21.Were there adequate, safe play areas outside? _____Where?______Please describe:_______Was the yard fenced in? ______
22.Did home appear to be child proof? (safety locks on cabinets, safety plugs in outlets, baby gates) Elaborate: ______
23.Were there reasonable security measures? (Locks on doors, windows etc.) _____
24. Were alcohol, cleaning agents, guns and other hazardous items kept out of the reach of children? Elaborate: ______
25.Was there a smoke detector in one or more rooms? ______Were the batteries operating? ______
26.Was there a telephone in the home? ______Were emergency numbers posted or kept anywhere? ______
27. Was the house sanitary? _____ Was there adequate provisions for garbage? _____
28. Give a general impression of the home (i.e. clean disheveled) ______
______
B.Employment Information
Name ______
Employment ______Salary ______
How Long ______Phone Number ______
Work Hours ______
Other income: ______
C.Criminal Background Information
Is this home assessment court ordered? ______Yes ______No
Has any resident of the home been the subject of a child abuse/neglect investigation?
____ Yes ______No If yes, please explain______
Has any resident of the home been convicted of a felony? ____ Yes ______No If yes, please explain: ______
D. Other
Were any health hazards observed? _____ Yes ______No Explain: ______
Are there any concerns? ____ Yes _____ No Explain: ______
______
CASA Volunteer/Date CASA Staff Member/Date
Information in this report is based on observations, interviews, and documents reviewed by the CASA Volunteer. The Montgomery County Juvenile Court CASA reserves the right to edit this report as information is received including on the date of the hearing. Montgomery County Juvenile Court CASA is unable to conduct criminal background checks or Children’s Services histories on any of the parties involved and, therefore, home visits consist only of Montgomery County Juvenile Court CASA’s observations and interviews. Montgomery County Juvenile Court CASA should not be the sole basis upon which the Court decides to place the minor child(ren).
The informationcontained in this report has been gathered as a courtesy. It is designed for informational purposes only and NOT to be used as the basis for placement of this child