#6. Family Service Tracking

WEEKLY FAMILY SERVICES SNAPSHOT
STAFF NAME ___________________________
WEEK: _________________________________

Family 1

Family 2

No contact with child or family this week
# home visits completed
% home visit time on child development
% home visit time on parenting
% home visit time on family needs
# days child attended EHS center
# days child attended partner center
Child attended an EHS parent-child group
activity with primary caregiver
Primary caregiver attended...
Prenatal education session
Parenting education session
Other parent training

D.43

Child received…
A developmental screening or
assessment?
A health screening (vision, hearing
dental, other)?
On-site services from a program partner
(such as immunizations, health care)?
Any referrals made to...
C
Health care provider?
Prenatal care provider?
Mental health care provider?
Disabilities services provider?
Part C?
Child care partner?
Other child care provider?
Other community service provider (such
as ESL, job training, housing
assistance provider)?
Family experienced change in...
Primary home visitor
Child’s teacher/classroom
Family service worker
C = Child

O = Other family member

O

C

O

Family 3

Family 4

Family 5

Family 6

Family 7

Family 8

Family 9

Family 10

Family 11

Family 12