MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION PARENTAL HOME VISIT CHECKLIST
INSTRUCTIONS: Worker should complete this form monthly during a visit to the family’s home. A basic safety assessment should be completed. Any narrative from the visit can be listed in the ‘Comments’ space. All persons present and their relationship to the head of household should be documented. Worker and family members will sign, and worker should provide a copy to the family. This form will become part of the case record and should be kept in the assessment and treatment services section.
Date/time of visit: /	Worker visiting home:
Household Address:
Case Name:	Case Manager:
Case Type: Family Centered Services (FCS) Family Centered Out of Home Care (FCOOHC)
SIGNATURES:
Children present for the visit but unable to sign their name should be noted in the comments section.
Parent’s signature	Date	Parent’s signature	Date
Child’s signature	Date	Child’s signature	Date
Child’s signature	Date	Child’s signature	Date
Child’s signature	Date	Child’s signature	Date
Worker’s signature	Date	Other household member	Date
(Relationship to parent)
DISCUSS WITH FAMILY AS APPROPRIATE: Staff should address only those areas that are/were of concern. If there is not or has not been a concern, staff do not need to address with the parent.
Familial interaction and communication styles Basic standards for environmental health and safety Resources needed in areas of budgeting, family planning, behavior management as requested by the family or directly related to child's out of home placement. Progress in treatment plan. Family's perception of treatment and of out of home care providers (if applicable) Reasons for removal and obstacles for Reunification (if applicable) Basic safety issues, as determined to be an area of need or concern, such as: Basic needs can be met (utilities operable, adequate food and clothing, etc.) Supervision (appropriate child care plan, concerns with drug/alcohol abuse, discipline techniques, etc.) Safety Hazards (weapons, medications and poisonous materials are inaccessible to children, no structural concerns with the household, etc.) Upcoming court proceedings and FST/PPRT meetings.

COMMENTS: (Please address all items discussed with parents. Serious and moderate needs from the CD-14A that have been corrected should also be addressed in this section.)
Next home visit is scheduled for: