Family Profile Six Month Supervision Plan Co-parent/Participant’s Participant’s name: _________________ name:__________ name: _____________________ age or EDC:__________________ Child’s Child’s Screening Checklist: Mental Health Screen: Score = _________ Referral Offered (required if score is equal to or greater than 16)? Yes No N/A Safety Screen: Positive = Yes No Referral Offered? Yes No N/A Follow-up from initial summary/previous six month plan: Priority Area Progress (e.g. referral follow-up, parent response, curriculum) Family Profile New Follow-up priorities: Health and wellness Education, job and life skills Parent’s and wellness Cognitive or developmental needs Child’s Health Mental Health and wellness Child development and nurturing parenting Social supports Community and personal safety Other: ____________________ Substance Use Concrete needs (clothes, food, financial, etc.) Attachment/Bonding Priority Area Strategies Curriculum Progress (e.g. rescreening, referrals, HV activities, (e.g. referral follow up, observations, or other materials, etc.) parent response, etc.) Potential areas for Family Goal Plan: Plan for next home visit: Home Visitor signature:_________________________________ Date:___________ Supervisor signature:___________________________________ Date:___________
Family Profile Six Month Supervision Plan Participant’s name: _________________ Co-parent/Participant’s name:__________ Child’s name: _____________________ Child’s age or EDC:__________________ Screening Checklist: Mental Health Screen: Score = _________ Referral Offered (required if score is equal to or greater than 16)? Yes No N/A Safety Screen: Positive = Yes No Referral Offered? Yes No N/A Follow-up from initial summary/previous six month plan: Priority Area Progress (e.g. referral follow-up, parent response, curriculum) Family Profile New Follow-up priorities: Parent’s Health and wellness Child’s Health and wellness Mental Health and wellness Community and personal safety Substance Use Concrete needs (clothes, food, financial, etc.) Attachment/Bonding Education, job and life skills Cognitive or developmental needs Child development and nurturing parenting Social supports Other: ____________________ Priority Area Strategies (e.g. rescreening, referrals, HV activities, observations, or other materials, etc.) Curriculum Progress (e.g. referral follow up, parent response, etc.) Potential areas for Family Goal Plan: Plan for next home visit: Home Visitor signature:_________________________________ Date:___________ Supervisor signature:___________________________________ Date:___________
59bec0d6eb7a4582bfafec9f1246147b.docx