ACTION PLAN Worksheet (sample)
ACTION PLAN Worksheet (sample)
Family Name: _________________________ Home Visitor: _______________________
Please check the services you would like to focus on during the next six months.
□ Information about babies, what they can do/need, how to teach them
□ Preparing my children for school
□ Keeping up with my child’s immunization and medical care
□ Toy lending library
□ How to calm a crying baby
□ Basic infant care
□ Seeing/meeting my baby’s needs
□ Activities to encourage my baby’s (child’s) development
□ Children’s books
□ How to teach my children to respect others and learn “right from wrong”
□ How to set limits with my children, how to say “no” and stick with it
□ Support, someone to talk to
□ Disciplining my children
□ Assistance in coordinating, getting to and from health care
□ Getting out of the house with children
□ Building my confidence as a parent
□ Domestic violence/family violence
□ Depression
□ Personal problems
□ Family planning, birth control
□ Assistance with drug or alcohol problems
□ Feeling better about myself
□ Referrals to community and medical services, such as:
□ Financial Assistance
□ Medical Assistance
□ Housing Assistance
□ Food Stamps
□ WIC
□ Education (GED, college)
□ Employment
□ Counseling
□ Recreation
□ Respite child care
□ Preschool
□ Head Start/Early Head Start
□ Health care (MD, PHN)
□ Immunizations
□ Reading/literacy
□ Couple/relationship problems
□ Help in solving family problems
□ Transportation
□ Learn to manage time, stress or anger
□ Managing my household
□ Parent support and activity groups and outings
□ Community support (church, friends, etc.)
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