PC1 ID:Click here to enter text.Date of Visit:Click here to enter text.
Home Visitor:Click here to enter text.Length of Visit:Click here to enter text.
Age of Target Child (or due date):Click here to enter text.☐Prenatal☐PostnatalLevel: ☐1P ☐1 ☐2 ☐3 ☐4 ☐X
Who was present? ☐MOB ☐FOB ☐TC ☐Sibling(s) ☐Friend(s) ☐Other(s): Click here to enter text.
Plan for this visit/Follow-up from previous visit:
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I. HOME VISITOR’S OBSERVATIONS
A. Describe the visit
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Anyone new living or staying in the home? ☐Yes ☐ No If Yes, who?
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Any other changes in household composition?
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Anything unusual about the visit or anything that altered the plans for the visit:
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B. Observations of Target Child (check all that apply)
Health:☐Appeared healthy ☐Appeared sick ☐Awake ☐Asleep ☐Medical/well-baby visits
☐Immunizations ☐ER visits
Mood: ☐Cheerful ☐Content ☐Withdrawn, unresponsive ☐Tired ☐Irritable
Appearance: ☐Physical needs appear met ☐Physical needs appear unmet
Comments: (including developmental milestones, health and safety):
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C. Observations of Parents (check all that apply)
Health:☐Appeared healthy ☐Appeared sick ☐Awake ☐Asleep ☐Medical/Prenatal/ER visits
Mood: ☐Cheerful ☐Content ☐Withdrawn, unresponsive ☐Tired ☐Irritable
Appearance: ☐Typical ☐Atypical
Comments: (including strengths, successes and challenges, health, safety, family planning and employment):
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D. Family Functioning and Home Environment (check all that apply)
☐Typical ☐Atypical ☐Crisis
Observations of siblings: Click here to enter text.
E. CHEERS: Observations of the Parent-Child Interaction (PCI)
Write 1-2 facts for each CHEERS aspect that represent the overall visit and frequency. For prenatal parents, address Expression and Empathy starting at 24 weeks and a 3rd aspect at 31 weeks.
Cues: Click here to enter text.
Holding: Click here to enter text.
Expression: Click here to enter text.
Empathy: Click here to enter text.
Rhythmicity/Reciprocity: Click here to enter text.
Smiles: Click here to enter text.
Overall Strengths: Click here to enter text.
Areas to Focus Support: Click here to enter text.
II. HOME VISITOR’S INTERVENTION
A. Reflective Strategies Used to Promote or Address PCI/CHEERS
Comments(note the reflective strategy used to support Parent-Child Interaction and why):
☐ATP ☐S-ATP ☐Feel Felt Found ☐Explore & Wonder
☐Normalizing ☐Solution-Focused Talk
Comments (note the reflective strategy used to support Parent-Child Interaction and why):Click here to enter text.
B. Other Interventions (check all that apply)
☐Curriculum: Click here to enter text.
☐Other handouts: Click here to enter text.
☐Child Development activities: Click here to enter text.
☐Father-specific support: Click here to enter text.
☐Videotaping: Click here to enter text.
☐Level Change discussion:Click here to enter text.
☐Other:Click here to enter text.
Comments:
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III. PARENTS’ RESPONSE (check all that apply)
☐Interested, engaged in discussion ☐Asked questions ☐Wanted more information ☐Not interested
☐Contributed observations and ideas
Comments:
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IV. ASSESSMENTS AND SCREENING TOOLS(check all that apply to this visit)
A. Discussion of:
☐Parent Survey content: Click here to enter text.
B. Administration or discussion of:
☐ASQ/ASQ-SE: Click here to enter text.
☐PSI: Click here to enter text.
☐Other Assessments: Click here to enter text.
V. FGP
☐Discussed FGP process and content
Comments:
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VI. TRANSITION PLAN (check all that apply)
☐N/A☐Discussed☐Plan finalized☐Transition completed
☐Parent(s) Declined
Comments:
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VII. PLANS FOR NEXT VISIT
Date of next visit: Click here to enter date.
Plans for supporting the family in the next visit:
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VIII. REFERRALS AND FOLLOW-UP ON REFERRALS (include referrals related to CD, PCI, family functioning and home environment, assessment and FGP)
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Paperwork due:Click here to enter a date.
FSW Signature:Click here to enter text.Supervisor review (initials): Click here to enter text.
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HFNY HOME VISIT NARRATIVE 4/17/ 2017