Visitation Services Monthly Summary Report

Supervised Family Time

Monthly Report
Month & Year
Case Assigned To:
Sibling Name:

First NameLast Name
Visiting Parent

First NameLast Name
Visiting Parent

First NameLast Name
Sibling VisitationParent/ Child(ren)Sibling/ Parent Child(ren)
Attendance

Date/Time for Visitation Services

Rows	Date	Parent(s) Arrival Time	Child(ren) Arrival Time	End of Visit Time	Date	Parent(s) Arrival Time	Child(ren) Arrival Time	End of Visit Time
Week (1)
Week (2)
Week (3)
Week (4)
Week (5)

Reason(s) for Missed Visit:
Family Members Approved for Visitation Services:
Absent Family Members/Date(s):
Guest & Collateral(s):
Parent(s) Status
Arrived on TimeAppear Ready for VisitSafety ConcernsMake Eye ContactVerbal GreetingHugged Child(ren)
Explanation of Parent Status:
Parent(s) does not participate in drug screening at TCH.Parent(s) participated in drug screening at TCH pre/post visit.
Child(ren) Status
Arrived on TimeAppear Ready for VisitObservable Concerns Upon ArrivalSafety ConcernsMake Eye ContactVerbal GreetingHugged Parent(s)Engaged w/ Toy rather than ParentInfant
Explanation of Child(ren) Status:
Visitation Goal Planning

Visitation Goals for this Month:

Rows	Visitation Goal	Objective(s)
1.
2.
3.

Goals Addressed This Month:
Supervised Family Time

Overview of the Family Visit
Siblings engage in age-appropriate activities and games during the visit to encourage bonding.Siblings have items needed for their basic needs.Siblings able to play and attend to their basic needs without the support of staff.Not Applicable
Explanation:
Parent adheres to routine for snack/meal time, play time, and clean up time.Parent communicate expectation and offers guidance to the child(ren) with implementing routine.Parent and child(ren) celebrate successful completion of routine with positive reinforcement.Not Applicable
Explanation:
Parent participate in playtime activities initiated by the child(ren).Parent encouraged the child's creativity and imaginative play ideas.Parent adapts playtime activities to match the child's interest and preferences.Both parent/child(ren) share laughter and smiles while participating in the activities.Parent offers opportunity for infant/toddler development through the use of implementing age-appropriate toys.Not Applicable
Explanation:
Parent promotes educational experiences during the visit.Parent participate in a joint learning experience through reading, creative projects, and other projects.Parent uses imaginative play as teachable moments.Parents incorporate infant/toddler development to foster the learning experiences.Not Applicable
Explanation:
Parent show interest in the conversation topics initiated by the child(ren).Parent acknowledges and validates feelings during discussion.Parent models problem solving skills, addressing conflict calmly.Parent involves the child in the decision making process and encourages them to think of solutions.Parent expressed their feelings without blaming the child, and they are able to find balance in the resolution.Not Applicable
Explanation:
Behavioral Concerns/Interventions
Yes (see below)NoNot Applicable
Parent(s) addresses behaviorsParent(s) request/assistance neededFSS identified teachable momentsFSS modeled disciplinary techniqueParent(s) receptive to support/feedbackParent(s) not receptive to support/feedbackNo behaviors to report.Sibling addresses behaviors.
Behavioral Concerns/ Interventions:
Supportive Visitation Services
DFCS did not refer the parent(s) to participate in the Nurturing Parenting curriculum offered by TCH. However, the family agrees to participate in the curriculum.DFCS referred the parent(s) to participate in the Nurturing Parenting curriculum offered by TCH.This family participates in sibling visitation services. FSS will assess the needs of the children and follow up support may be provided by the Visitation Director.There is no DFCS involvement. However, the family agrees to participate in the curriculum when needed and other resources that will support the visits.The parents have completed the requirements for the Nurturing Parenting. We will continue to provide supports and connect the family to resources as needed.
Parent Coaching Summary:
Family Support Summary:
Impact of Separation
Verbal GoodbyeHug MotherHug FatherParent Initiates AffectionParent(s) prepare children for end of the visit.Parent(s) Assist w/ DepartureHugs Sibling(s)Delayed DepartureNeeds Additional Prompting from StaffInfant
Explanation:
Case Management
Case Management/Explanation of Support(s):
No, the parent(s) continue to comply with TCH's policy. The parent(s) are engaged with the child(ren) during the visits, and attend to the child(ren) basic needs.No, this is a sibling visit, and the children are engage with each other and they play well together.
Case Concerns: Yes (see below)
Information /Referral & Life Skills
Critical Incident
YesNoIf critical, (see incident report)
Date of Incident

MonthDayYear
Date
Additional Information regarding incident(s):
Family Support Specialist

First NameLast Name
Signature
Date

MonthDayYear
Date
Family Support Specialist

First NameLast Name
Signature
Date

MonthDayYear
Date
(Reviewed by) Visitation Director

First NameLast Name
Signature
Date

MonthDayYear
Date
The observations of parent-child or sibling contacts which have occured in a structured and protected setting. No prediction is intended about how contact between the families might occur in a less protected setting and without supervision. Care should be exercised by the users of these observations in making such predictions.
Should be Empty:

Supervised Family Time

Attendance

Parent(s) Status

Child(ren) Status

Visitation Goal Planning

Supervised Family Time

Behavioral Concerns/Interventions

Supportive Visitation Services

Impact of Separation

Case Management

Critical Incident