Healthy Families New York



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 ? Postnatal & Level: ? 1P ? 1 ? 2 ? 3 ? 4 ? XWho 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: Click here to enter text. I. HOME VISITOR’S OBSERVATIONSA. Describe the visitClick here to enter text.Anyone new living or staying in the home? ? Yes ? No If Yes, who? Click here to enter text.Any other changes in household composition? Click here to enter text.Anything unusual about the visit or anything that altered the plans for the visit:Click here to enter text.B. Observations of Target Child (check all that apply) Health:? Appeared healthy ? Appeared sick ? Awake ? Asleep ? Medical/well-baby visits ? Immunizations ? ER visitsMood: ? Cheerful ? Content ? Withdrawn, unresponsive ? Tired ? IrritableAppearance: ? Physical needs appear met ? Physical needs appear unmetComments: (including developmental milestones, health and safety):Click here to enter text.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 Withdrawn, unresponsive ?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 ? IrritableAppearance: ? Typical ? AtypicalComments: (including strengths, successes and challenges, health, safety, family planning and employment):Click here to enter text.D. Family Functioning and Home Environment (check all that apply) ? Typical ? Atypical ? CrisisObservations 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 INTERVENTIONA. Reflective Strategies Used to Promote or Address PCI/CHEERSComments?(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:Click here to enter text.III. PARENTS’ RESPONSE (check all that apply)? Interested, engaged in discussion ? Asked questions ? Wanted more information ? Not interested ? Contributed observations and ideasComments: Click here to enter text.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 contentComments:Click here to enter text.VI. TRANSITION PLAN (check all that apply)? N/A? Discussed? Plan finalized? Transition completed? Parent(s) DeclinedComments:Click here to enter text.VII. PLANS FOR NEXT VISITDate of next visit: Click here to enter date.Plans for supporting the family in the next visit:Click here to enter text.VIII. REFERRALS AND FOLLOW-UP ON REFERRALS (include referrals related to CD, PCI, family functioning and home environment, assessment and FGP)Click here to enter text.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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