H Standardized Assessment and Information Gathering Policy

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HEALTHY FAMILIES MASSACHUSETTS Standardized Assessment and Information Gathering Policy

September 2011Page 1

HEALTHY FAMILIES MASSACHUSETTS POLICIES & PROCEDURES STANDARDIZED ASSESSMENT & INFORMATION GATHERING

As families are identified and engaged in H EALTHY FAMILIES MASSACHUSETTS (HFM) services, itis critical for programs to know and understand their history, beliefs and knowledge baseregarding parenting and its associated stresses in order to effectively partner with them.Establishing a process that can serve the dual purposes of relationship building and informationgathering is key to program success. HFM has a standardized assessment and informationgathering process, to maintain consistency and tools that are used by all HFM programs. Thismethod of collecting initial information promotes family-centered service delivery.

HFM standardized assessment and information gathering policies and procedures are dividedinto the following sections:

Family Profile training requirements; Guidelines for administering the Family Profile; The Family Profile and service delivery; and Transferred participants; and Role of supervision in supporting the Family Profile process.

Attached to this policy are the following appendices: Appendix A: My View Tool

Appendix B: Prenatal Entry Guide (PREG) Appendix C: Prenatal Entry Guide Supplemental Information (PREG-SI) Appendix D: Postpartum Form (PPF) Appendix E: Participant Transfer Form (PTF) Appendix F: Family Profile Summary Sheet Appendix G: Family Profile Supervisors Checklist

RationaleThe Family Profile is the standard tool and process to assess the needs, strengths, challenges,and interests of all families in HFM during the period immediately after enrolling in theprogram. When completed, programs use the Family Profile to guide service delivery across allprogram components including goal setting, referrals and resources, home visiting, andsupervision. In addition to providing a snapshot of the family at enrollment, it serves as a toolto build trusting and effective working relationships between families and home visitors.Family Profile is designed to be administered as a guided interview using a conversationalapproach with families over the course of multiple visits.


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I. FAMILY PROFILE TRAINING REQUIREMENTS

A. Programs may decide which staff (e.g., coordinators, supervisors, home visitors, all ofthe above) will administer the Family Profile. HFM strongly encourages those staff whoprimarily deliver services be the primary administrators of the Family Profile.

B. All HFM staff members who will be completing the information gathering process andadministering the Family Profile must be trained in its goals, purpose, and use before administering the tools with participants. Staff not yet trained in the use of the FamilyProfile may shadow trained staff developing the tool with new families as part of theirorientation, provided the family consents to this arrangement. Shadow visits to observethe Family Profile will be made in coordination with the participants, home visitorsand/or intake staff, and the supervisor.

C. Only staff members who have attended the Family Profile CORE Topic Training mayadminister the Family Profile.

D. All HFM staff must attend The Family Profile CORE Topic Training (see the HFMTRAINING POLICY for required trainings).

E. The Family Profile CORE Topic training will include:

1. Training manual. Each trainee will receive their own copy of the manual forpractice and reference at their site. The manual will include:

Training materials and the theoretical background that describes what theFamily Profile measures are; and

Examples of the actual assessment forms to be used by HFM programs.

2. A one-day training session that includes: lecture-based discussion on interviewing, communication, and broaching

difficult topics with families; small group activities for trainees to practice interviewing skills; familiarization with each of the tools, including timeline for completion; hands-on practice with forms to familiarize all staff with them and for staff to

learn to use the Family Profile according to HFM best practices; and strategies for using supervision to strengthen the information gathering

process, as well individual home visitor skills.

3.

Trainers who meet the standards set by the HFM Training Center. These standardsare as follows: the trainer must have been selected by the HFM Training Coordinator, either

through procurement for trainers, or by invitation; the trainer must have at least two years experience working in the HFM

system;


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the trainer must have knowledge of, thorough experience in, or trainingability in the following topics: strengths and challenges of working withyoung families, child development, goal setting, interviewing skills,communication skills, maintaining boundaries, and administering the FamilyProfile. Trainers must have a current rsum on file with the HFM Training

Coordinator that demonstrates this knowledge; and the trainer must have successfully completed the HFM CORE Topic Trainingin the Family Profile. Trainers must have a current rsum on file with theHFM Training Coordinator that demonstrates this knowledge or evidencefrom the Childrens Trust Fund (CTF) training database that indicatesattendance.

II. GUIDELINES FOR ADMINISTERING THE FAMILY PROFILE

A. Family Profile Forms

1. The Family Profile consists of the following forms: My View form Prenatal Entry Guide (PREG) Prenatal Entry Guide Supplemental Information (PREG-SI) Postpartum Form (PPF) Family Profile Summary Sheet Supervisor Checklist Family Profile Transfer form

2. My View : The HFM program will ask parents to fill out My View, which is the self-report form. Each parent, whether a primary or secondary participant, should receivehis or her own copy to fill out individually. My View is not intended to be completed byany other member of the extended family. HFM staff can be present when a parentcompletes the My View; however, the parent(s) may fill it out independently outside ofa home visit as well. HFM staff may offer support and guidance, but parents areencouraged to fill out My View as independently as possible. The earlier the My View iscompleted, the more relevant the information gathered is. It may or may not coincidewith the first Family Profile visit.

3. Prenatal Entry Guide (PREG), Prenatal Entry Guide Supplemental Information(PREG-SI), and Postpartum Form (PPF): The Family Profile has two versions, thePrenatal Entry Guide (PREG) with its supplement (PREG-SI) and the Postpartum Form(PPF). The content of the assessments are virtually the same, but tailored to engagefamilies who enter the program at different points in their parenting experience toensure the program may best serve their needs. HFM staff determine the appropriateform, using the criteria as follows:

The PREG must to be completed with participants who enroll prenatally.


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NOTE: The Prenatal Entry Guide Supplemental Information (PREG-SI) must becompleted once the baby is born. Waiting one month postpartum to complete thePREG-SI is recommended to give the family time to adjust. The PREG-SI must becompleted within 4 visits or two months of the birth of the baby.

The PPF must to be completed with participants who enroll in the postpartum period.

NOTE: The PREG, PREG-SI, and PPF contain two tiers of questions. First tierquestions are in bold lettering on the forms. HFM staff must ask participants every

first tier question while completing the Family Profile. Participants may decline toanswer any question. Second tier questions are not in bold print, and HFM staffmust make every attempt to ask these questions.

4. Family Profile Summary Sheet: After the completion of the PREG or PPF form,the staff person completes the Summary Sheet. The Summary Sheet bringstogether information that the staff person has learned throughout the guided

interview process with the family and helps him/her make plans for servicedelivery including goal setting.

5. Supervisor Checklist : Supervisors complete the Supervisor Checklist to helpkeep staff on track in their administration of the Family Profile with participants.

6. Family Profile Transfer Form (PTF): When a participant transfer to a program,the receiving program completes the (PTF) and a new My View in order to havethe most up-to-date information regarding the participant and how his/hermove has impacted his/her social support system, as well as to identify newstrengths, needs and resources as a result of the move. The PTF must be

completed within the first four visits, or 6 weeks of enrollment.

NOTE: Programs may use other tools and processes in addition to the Family Profile, ifdesired, but may not supplant the Family Profile. If choosing additional tools as part of theassessment and information gathering process, HFMIT encourages programs and theiragencies to reduce duplication of effort in order to minimize the likelihood of participantsand staff feeling overwhelmed.

B. Deadlines & Documentation

1. The Family Profile must be completed with a newly enrolled participant family

within 45 days after the first home visit. Staff must document in the PDS the datethey complete the Family Profile. The Family Profile is complete when: the participant has finished responding to questions on the My View form and

discussed his/her responses with a staff person, the staff person has documented all participant responses to the questions on

either the PREG or PPF form as appropriate based on the parenting status of theparticipant,


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the staff person has completed the Family Profile Summary Sheet, and the staff person has reviewed the Family Profile Summary Sheet with his/her

supervisor and the supervisor has signed it.

NOTE: If a staff person approaches the end of the 45-day period for completing the

Family Profile and has not successfully covered all questions in the assessment, s/heshould complete the Family Profile Summary Sheet based on the information obtainedand discuss it with his/her supervisor to ensure that the tool is finished by the deadline.HFMIT requires that staff complete the Summary Sheet before the 45 days expiresbecause Family Profile is an initial assessment tool and must f ocus on participantsexperiences at the onset of services.

Supervision Spotlight : If a staff person regularly struggles to complete the FamilyProfile within the 45-day period, supervisors must explore why s/he is unable to coverall the questions and strategize ways to successfully finish the assessment with futureparticipants.

2. Upon completion and review of the Family Profile, HFM staff will add all formsto the participants paper record. The Family Profile forms to be included are:

My View form; PREG and PREG-SI (when completed), or PPF form; and Family Profile Summary Sheet.

NOTE: As with all other HFM documentation, the Family Profile must be completed inEnglish. The exception is the My View form, which is currently available in English,Spanish, and Portuguese. Programs must not translate any written portion of theFamily Profile; only CTF may translate statewide program materials.

C. Family Profile Use & Quality Considerations1. Confidentiality: As with all other materials, information collected about program

participants using the Family Profile is confidential. The program should havesigned consent forms from all family members participating in the Family Profile,except in instances where there is documentation that participants have declined tosign the program consent form. Staff should also review confidentiality with thefamily during the Family Profile process.

2. Administration of the Family Profile: Programs may decide which staff, e.g.coordinators, supervisors, home visitors, or all of the above, will administer the

Family Profile. HFMIT strongly encourages programs to select home visitors toadminister the Family Profile. If the primary home visitor assigned to a participantis not administering the Family Profile, HFMIT also strongly recommends that thehome visitor be present at the home visits involving the tool to support relationshipbuilding.


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3. Family Inclusion: Whenever possible, the Family Profile is to be administered withboth the mother and the father present during the interview process. The FamilyProfile was designed to communicate one of HFMs core values: respect for thefamily. HFM staff knows the benefits of having fathers involved in their childrenslives and respect that a fathers involvement is unique in each family. HFM staff

should not overlook the importance of a primary or secondary participant father inthis process and the valuable input he could provide in the information gatheringprocess.

4. Participant Competence and Comfort: HFM staff should be aware of the ranges incompetence and comfort each young parent (mother and father) has in the followingareas while developing the profile:

Experiences the parent has in caring for children Birth order of the parent(s) Cognitive development and problem-solving abilities Level of personal awareness including (but not limited to): personality traits,

strengths and challenges Language preference Culture and ethnicity

5. HFM Staff Competence and Comfort : In interacting with families, HFM staff shouldbe mindful of their own:

Individual experience level Comfort administering the Family Profile Cultural competence Personal temperament and interviewing style

6. Extended Family: The Family Profile process can be challenging and may includeadditional members of the extended family during the visit. HFM staff may includerelevant information gathered from extended family members, with the primaryparticipant(s) approval, to be as inclusive in the assessment process as possible. Anexception to this practice is that the My View is intended only for participants tocomplete.

7. Right to Decline: Participant family members may decline to answer any questionson the Family Profile form. This will not affect their participation in the program.Documentation of their decision to decline to answer should be noted on the toolitself as well as in the Family Profile Summary.

8. Documentation: The information gathered while completing the Family Profileshould be entered into the Participant Data System (PDS) as part of the home visitrecord for each visit . See Family Profile and Information Gathering trainingmaterials on this for further guidance.

9. HFM IFSP : Goals identified through the administration of Family Profile should beexplicitly linked to the initial HFM IFSP. Research shows that the most effective


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home visiting programs are ones that link initial strengths and needs to goal setting,which guides service delivery. The goal of each form is to determine the familysituation at the point of requesting services to learn how HFM can most effectivelyserve their needs in a timely and strengths-based manner.

For more information, please refer to the HFM GOAL SETTING POLICY, or submit a TAticket via the TA Help Desk at [email protected]

10. Follow-up: Referrals/resource needs identified during the Family Profile processshould be addressed as soon as they are noted.

III. THE FAMILY PROFILE AND SERVICE DELIVERY The program staff member and his or her supervisor must review the gathered informationand discuss strategies for effective service delivery based on the unique strengths and needsof the participant. The program staff member and the participant review issues that arenoted in the Family Profile process and discuss how these will be incorporated into service

delivery, including IFSPs, home visit content, and referrals to community agencies. Allprograms follow this process to ensure that all HFM participants across all sites experienceconsistent initiation of services.

IV. TRANSFERRED PARTICIPANTS When participants move within Massachusetts and are still eligible for HFM services, theycan opt to transfer to the HFM program that covers the area to which they have relocated.When this happens, programs must complete the transfer protocol (please see the HFMSERVICE TRANSITIONS POLICY). This protocol includes completing the Family ProfileParticipant Transfer Form (PTF) and a new My View in order to have the most up-to-dateinformation regarding the participant and how this move has impacted their social supportsystem, as well as to identify new strengths, needs and resources as a result of the move.The PTF must be completed within the first four visits, or 6 weeks of enrollment. Programsare advised to seek the participants consent to have access to the former programs FamilyProfile to gain a better understanding of historical information. For more guidance on thisprocess, please refer to the HFM SERVICE TRANSITIONS POLICY.

V. RE-ENROLLED PARTICIPANTS When participants re-enroll in services programs should use this opportunity to reassess theparticipant s circumstance at the most recent enrollment. Programs are encourage to use theMy View with all re-enrolled participants as a tool for gathering updated information andinforming service plans.

VI. ROLE OF SUPERVISION IN SUPPORTING THE FAMILY PROFILE PROCESSSupervision is an important component of successfully using the Family Profile to guideservice delivery. Use of the Family Profile will allow supervisors and home visitors/HFMstaff to communicate more effectively about a familys strengths and needs. Supervisorsresponsibilities include two areas of focus: 1) consistent strengths-based service deliverythrough the administration of the Family Profile, and 2) supporting staff in building their
http://mctfcommunity.org/http://mctfcommunity.org/http://mctfcommunity.org/http://mctfcommunity.org/


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skill- and comfort level in administering the Family Profile. The responsibilities of thesupervisor are to ensure that:

the Family Profile is used by all HFM staff in accordance with HFM policies,including the requirement that the program staff may not administer the tool untils/he has attended the Family Profile training;

the HFM staff member promotes the familys best interest during the process; all the required (in bold on the form) questions are asked of the participant, orappropriate documentation of why these were not asked is included on the FamilyProfile forms;

the Family Profile is administered in a culturally competent and thorough manner; all issues raised by the participant are discussed in supervision sessions, with the

goal of addressing the issues in home visits; ongoing case review includes periodic discussion of issues raised during the Family

Profile process, as well as status of program interventions; ensure the existence of the link between strengths, needs, and goals identified in the

Family Profile process, and the development of the initial Individualized Family

Support Plan (IFSP), as well as subsequent IFSPs as appropriate; ensure that the Family Profile Summary is completed in a thoughtful, professionalmanner;

review all completed Family Profile forms, complete the Supervisor Checklist, andfile the Supervisor Checklist in supervision logs;

ensure that all Family Profile paperwork is completed , and filed in the participantspaper record; and

review home visit records to ensure that Family Profile information is added to thePDS according to HFM guidelines.

Please contact the HFMIT for Technical Assistance (TA) regarding this policy via the TA Help

Desk at [email protected]
mailto:[email protected]:[email protected]:[email protected]:[email protected]


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1 Mother or Father Self Report

2001 MA Childrens Trust Fund/HF Copy double sided on blue paper

Name:____________________________ Date: _________________

My ViewHealthy Families is interested in how YOU feel about things now, as well as how youfeel about parenting based on how you were raised. Please feel free to skip any questionsyou do not want to answer or ask if anything is unclear.

RESOURCE NEEDS

1. Would you like information or assistance in any of the following areas? (Please check)

Comments

Family planning

Early Intervention

Pregnancy info

Paying for medical/health care

Child Birth Classes

Labor Coach

Finding medical care for your family

Housing or housing conditions

Child Care

Child Development

Building my confidence as a parentIdeas about discipline

How to calm a crying baby

Managing time, stress, and anger

Feeding plans

Food WIC

Clothing for you or your child (ex. Diapers)

Baby furniture or other supplies (ex. Car seat)

Transportation

Dental, Vision or hearing services

Care for other family members

Group Support

Substance Abuse Services

Table continued on reverse


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Comments

Mental Health Services

Domestic Violence Services

Finding time for myself

Getting a jobFinishing school or job training

Emergency plan (phone, contact,

transportation)

Other

STRESS/COPING

We all get stressed out sometimes, especially when tired or frustrated. But the way wedeal with stress is different for everyone.

2. How do you rate your own stress right now?

Not at all stressed A little stressed Somewhat stressed Very stressed1 2 3 4

3. Right now, what is the major cause of stress for you?

4. Have any of the following things happened to you in the past year?New partner Broke up with partner

Married Divorced

Left School Started in new school

Changed Jobs Lost my job

Moved Someone close to me died

Someone close to me left Parents separated

Had a serious illness or injury Not enough food for my family

Felt unsafe in my own house Felt unsafe in my neighborhood

Ran away from home Behind on my rent or utilities

No money for transportation Had legal problems

Trouble sleeping Overwhelming debts or money problem

Attempted suicide Saw a therapist


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5. Describe the different ways you sometimes cope with stress.

I try to figure out why Im angry I go to sleep

I talk things over I cry

I get out of the house I yellI go to my room I get some exercise

I throw things I hit things

I drink or take drugs I call a friend

I call people names I hit people

I listen to music I do other things: ______________

6. What kinds of feelings have you been having lately?

Not at all Once in a while Sometimes A LotI have frequent headaches. 1 2 3 4

I worry a lot. 1 2 3 4

I feel exhausted and usually lack energy. 1 2 3 4

I feel sad or blue. 1 2 3 4

I make time for myself. 1 2 3 4

I am eager to do things. 1 2 3 4

I am excited about things. 1 2 3 4

I feel happy about my life. 1 2 3 4

I have had a change in appetite. 1 2 3 4

I am often irritable. 1 2 3 4

I frequently cry. 1 2 3 4

I am over-sensitive. 1 2 3 4

I have excess energy. 1 2 3 4

I have changed my sleeping habits. 1 2 3 4

I have frightening thoughts. 1 2 3 4

I dont feel I am good enough. 1 2 3 4

I am seeing/hearing unusual things. 1 2 3 4

I lose interest in enjoyable activities. 1 2 3 4

I have feelings of hopelessness. 1 2 3 4

I am confident about myself. 1 2 3 4


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SUPPORT

7. How are you getting along with your parents and family lately?

Not Well A little OK Good Enough Very Well

1 2 3 4

8. How are you getting along with the other parent? (or your current partner if different)

Not Well A little OK Good Enough Very Well

1 2 3 4

9. What contact do/will you have with the other parent?

Less then I need Right Amount More then I need Too Much

1 2 3 4

10. How much support and help are you getting from others in general?

Less then I need Right Amount More then I need Too Much1 2 3 4

Healthy Families can be of most use to you when you receive weekly home visits.What day and time each week works best for you for regular visits?

Day: ______________________________ Time: ______________________________


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Copy double sided on blue paper. 2001 MA Childrens Trust Fund/HF

Nome:____________________________ Data: _________________

My View/A MINHA OPINIOHealthy Families/Familias Saudveis est interessado em saber como voc sente em seruma me ou um pai, e como foi a sua criao. No obrigatorio preencher tudo, mas faafavor de perguntar se alguma coisa precisa ser esclarecida.

NECESSIDADES1. Voc gostaria de informao ou assistncia com: (por favor marcar)

ComentriosContracepo

Early Intervention/interveno prvia

Informao sobre a gravidez

Pagamentos de seguro mdico

Aulas prenatais

Assistncia de parto (dar a luz)

Seguro mdico para toda famlia

Alojamento

Servios de creche

O desenvolvimento da criana

Como aumentar sua confiana sobre ser uma

me ou um paiIdias sobre a disciplina

Como acalmar um beb choro

Administrao do seu tempo e estresse

Plano de nutrio para o seu beb

Nutrio WIC Programa

Roupa para si ou sua criana, como fraldas

Mobilias para crianas, como a cadeira de

segurana

Transporte

Servios dentais, ou mdicos (como viso)

Assitncia para outras pessoas na sua famlia

Grupos de apoio

Servios sobre o abuso de substncias

Table continued on reverse


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ComentriosServios de sade mental; terapia

Servios de violncia domstica

Achando tempo para mim

Encontrar emprego

Acabando escola, ou treinamento de trabalho

Plano de emergncia (telefone, contato,

transporte)

Outro

COMO ENFRENTAR ESTRESSENs algumas vezes ficamos estressados, especialmente quando estamos cansados oufrustrados. Porem, nos somos differentes na maneira que lidamos com estressantes.

2. Como est o seu nivel de estresse?

Nao tenho estresse Um pouco estrassado Estou estrassado Muito estrassado1 2 3 4

3. Neste momento, quais so seus estressantes?

4. No ano anterior, o que aconteceu com voc?

Novo (a) companheiro (a) Acabei com o meu relacionamento

Casei-me Divorciou

Parei com a escola Comeou em uma nova escola

Troquei de trabalho Perdi o emprego

Mudei de casa Tive uma morte na familia

Uma pessoa querida me deixou Os meus pais separaram-se

Tive uma doena grave No tenho comida suficiente em casa

Estou em perigo dentro de casa Sinto em perigo onde eu moro

Fugi de casa Estou atrazada com pagamentos

Sem dinheiro para transporte Tive problemas com assuntos legais

Tenho insnia Tive problemas graves com dinheiro

Tentei suicidio Tive tratamento com um terapista


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5. Como so as maneiras que voc enfrenta estresse?

Penso no estrese e porque estou zangada(o) Eu dormo

Eu falo com algum Eu choro

Eu saio de casa Eu grito

Eu vou para o meu quarto Eu fao exerccio

Eu atiro/jogo coisas Eu bato nas coisas

Bebo lcool ou uso drogas Eu chamo um amigo

Eu insulto as pessoas Eu bato nas pessoas

Eu ouo msica Eu fao outras coisas: _____________

6. O que voc vem sentindo ultimamente?

nunca algumas vezes muitas vezes sempre

Tenho dores de cabea com frequncia. 1 2 3 4

Estou preocupada. 1 2 3 4

Estou cansada e sem energia. 1 2 3 4

Eu estou e me sinto triste. 1 2 3 4

Eu fao tempo so para mim. 1 2 3 4

Eu tenho vontade de fazer as coisas. 1 2 3 4

Tenho alegria sobre coisas. 1 2 3 4

Estou feliz com a minha vida. 1 2 3 4

O meu apetite mudou. 1 2 3 4

Eu estou sempre iritada. 1 2 3 4

Eu choro com frequncia. 1 2 3 4

Eu estou muito sensvel. 1 2 3 4

Eu tenho muita energia. 1 2 3 4

Mudei a minha rotina de dormir. 1 2 3 4

Eu tenho pensamentos assustantes. 1 2 3 4

Eu no sinto-me uma pessoa boa. 1 2 3 4

Eu vejo ou ouo coisas anormais. 1 2 3 4

Perdi interesse em atividades interessantes. 1 2 3 4

Estou sem esperana. 1 2 3 4

Tenho confiana em minha pessoa. 1 2 3 4


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APOIO/ASSISTNCIA

7. Como est lidando com os seus pais e a sua famlia ultimamente?

Nada bem Um pouco Mais ou menos Muito bem1 2 3 4

8. Como est lidando com o pai ou mae da sua criana? Ou com o seu companheiro/a?

Nada bem Um pouco Mais ou menos Muito bem

1 2 3 4

9. Esta envolvido, ou tem contato com o pai ou me da sua criana?

Menos do que eu preciso O necessrio Mais do que eu quero Muito

1 2 3 4

10. Em geral, quanto apoio/assistncia tem das outras pessoas?

Menos do que eu preciso O necessrio Mais do que eu quero Muito

1 2 3 4

O programa Healthy Families/Familias Saudveis mais util quando voc recebe visitas

semanais. Qual hora e melhor dia da semana melhor para voc receber visitas

regularmente?


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Informe de Madre o Padre

2005 MA Childrens Trust Fund/HF

Copy double sided on blue paper

1

Nombre: ____________________________ Fecha: __________________

Mi Punto de VistaEl programa Healthy Families se interesa en saber como Usted se siente acerca de las cosas deahora y como usted se siente en ser Padre, basado en como usted Fue criado.Por Favor sintase libre de saltar cualquier pregunta que usted no quiere responder o preguntes alguna porcin no esta clara.

Recursos Necesarios:

1. Le gustara informacin o asistencia en alguna de las siguientes reas? (Por Favor demarcar)

Comentarios

Planificacin FamiliarIntervencin TempranaInformacin de EmbarazoComo pagar por servicios medico / cuidado de saludClases PrenatalPersona de apoyo de Parto

Encontrando cuidado medico para su familia

Vivienda o condiciones de ViviendaCuidado de NioDesarrollo del NioDesarrollando mi confianza como PadreIdeas acerca la disciplinaComo calmar a un nio que esta llorandoAdministracin de tiempo, estrs y enojoPlanes de amamantarComida / Programa de WICRopa para usted o su hijo (Ej. paales)Muebles de Bebe o otros suplementos ( Ej. Silla deseguridad para el carro)TransportacinServicios: Dental, de la Vista o auditivosCuido para otros miembros de la familia

Grupos de Apoyo


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2

ComentariosServicios para abuso de substanciasServicios de ayuda mentalServicios de violencia domesticaEncontrar tiempo para m mismo/a

Obtener un trabajoTerminar la escuela o entrenamiento de trabajoPlan de emergencia (nmeros de telfono, contactos,transportacin)Otros

SOBRELLEVANDO EL ESTRESTodos tenemos estrs algunas veces, especialmente cuando uno esta cansado o frustrado. Pero

la manera de tratar con el estrs es diferente para cada persona.2. Cmo considera usted su propio estrs en estos momentos?

No estoy estresada/o Estoy un poco estresada/o Estoy algo estresada/o EstoyMuy estresada/o

1 2 3 4

3. En estos momentos, cual es la causa principal de estrs para usted?

4. En este ao pasado le ha sucedido alguno de lo siguiente?

Tengo Nueva pareja Termine con mi pareja

Me he casado Me Divorcie

Abandone la escuela Empec una nueva escuela

Cambie de trabajo Perd mi trabajo

Me mude de direccin Alguien cercano a m muri

Alguien cercano a mi se fue Mis Padres se separaron

Tuve una herida /enfermedad seria No haba suficiente comida para mi familia

Me siento inseguro/a en mi propia casa Me siento inseguro/a en mi propio vecindario

Abandone el hogar Estoy Atrasado/a en mi renta o utilidades


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3

No tengo dinero para transportacin Tengo problemas legales

He Atentado suicidio Tengo Problemas para dormir

Tengo Dbitos agobiados o problemas de dinero Veo a un terapista

5. Describa las diferente maneras en que usted sobrelleva el estrs?

Trato de comprender l porque yo estoy enojado/a me voy a dormir

hablo con alguien lloro

voy afuera de la casa grito

me voy a mi dormitorio hago algo de ejercicio

tiro las cosas golpeo cosas

tomo o consumo drogas llamo a un amigo insulto a otras personas golpeo personas

escucho msica hago otras cosas

6. Que tipo de sentimientos a tenido usted recientemente?

Nunca Muy Poco A veces Mucho

tengo dolor de cabeza frecuentemente 1 2 3 4

me preocupo mucho 1 2 3 4

me siento cansado y usualmente sin energa 1 2 3 4

me siento triste 1 2 3 4

tomo tiempo para m mismo 1 2 3 4

estoy ansioso para hacer cosas 1 2 3 4

me siento feliz acerca de mi vida 1 2 3 4

estoy teniendo cambios con mi apetito 1 2 3 4

estoy frecuentemente irritado 1 2 3 4

lloro con frecuencia 1 2 3 4

estoy sobre sensible 1 2 3 4

tengo energa en exceso 1 2 3 4

cambie mi habito de dormir 1 2 3 4


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4

Nunca Muy Poco A veces Mucho

tengo pensamientos que asustan 1 2 3 4

no me siento que soy una persona de valor 1 2 3 4

estoy viendo / escuchando cosas raras 1 2 3 4

pierdo inters en cosas que antes me animaban 1 2 3 4me siento sin esperanza 1 2 3 4

me siento seguro de m mismo 1 2 3 4

APOYO

7. Cmo esta usted llevndose con sus parientes y su familia recientemente?

No muy bien Un poco bien Bastante bien Muy bien1 2 3 4

8. Cmo s esta llevando con el otro pariente de su bebe?(o su pareja si es alguien diferente)

No muy bien Un poco bien Bastante bien Muy bien1 2 3 4

9. Que contacto tiene/ tendr usted con el otro pariente?

Menos de lo que necesito Monto exacto Mas de lo que necesito Muchsimo1 2 3 4

10 Cunto apoyo y ayuda obtiene usted de otros en general?

Menos de lo que necesito Monto exacto Mas de lo que necesito Muchsimo1 2 3 4


21/70

1 Prenatal Entry Guide (PREG)

Copy double sided on green paper 2001 MA Childrens Trust Fund/HF

Name of Interviewer: ___________________________ Date started: ____/____/____ Participant(s) in interview: ______________________ Date completed: ____/____/____

______________________________________________________________________________

PARTICIPANT INFORMATION: (Father participant information on back) 1. Name: __________________________________________________ 2. DOB: _______________ 3. Address: ________________________________________________________________________ 4. Phone: _________________________ 5. Babys Due Date: ___________________

HOME ENVIRONMENT:

6. What do you rely on for transportation?

Mother: Father:Have own drivers license

Walk

Have own car

Public Transportation (Bus, subway, etc)

Family transport

No reliable transportation

Friends transport

Other (please describe)____________

Have own drivers license

Walk

Have own car


Family transport


Friends transport


7. Are you planning on changing your living situation after the baby is born?

Mother: Father:

NO YES

If yes, explain:

NO YES

If yes, explain:

8. Do you feel safe where you live?

Mother: Father:

NO YES

If no, explain:

NO YES

If no, explain:


22/70



PARTICIPANT INFORMATION:

1. Name: __________________________________________________ 2. DOB: _______________ 3. Address: ________________________________________________________________________ 4. Phone: _________________________


23/70



PREGNANCY EXPERIENCE:

Mothers and fathers often tell us they have different feelings about pregnancy.

9. When you first found out you were going to have a baby, how did YOU feel?

Mother: Father:

10. How do you feel about it now?

Mother: Father:

11. How do your family members feel about your pregnancy?

Mother: Father:

12. How do your friends feel about your pregnancy?

Mother: Father:

HEALTH:

13. How would you say your health is?


24/70



14. What are your eating habits/appetite like?

15.

Mother: Father:

Are you seeing someone for prenatal care? Are you attending prenatal visits?NO YES

If yes, please list contact information:

NAME:

ADDRESS:

PHONE:

NO YES

16. Mo. Prenatal care began: ___________

Most recent visit was: _________________ Next visit is: _________________

17.

Mother: Father:

Are you satisfied with the health care you are

receiving?

NO YES

If no, explain:

Are you satisfied with experience/involvement with

prenatal visits?

NO YES

If no, explain:

18. Do you feel comfortable asking your doctor questions when you may not understand what he/she said?

NO YES

19. What plans have you made for your labor and delivery?

Mother: Father:

20.

Mother: Father:

Do you have someone to be with you during the

delivery?

NO YES

If yes, who?

Are you planning on being there for delivery?

NO YES


25/70



21. Do you have specific concerns or questions about pregnancy and delivery?

Mother: Father:

22. Did you:

Mother: Father:

Plan for this pregnancy?

Consider terminating the pregnancy?

Consider adoption?

Plan for this pregnancy?

Consider terminating the pregnancy?

Consider adoption?

23. Have you ever thought about a pediatrician for the baby?

NO YES

If yes, do you already have a contact?

NAME:

ADDRESS:

PHONE:

24. Were you using birth control before you got pregnant?

Mother: Father:NO YES

If yes:

Shots (Depo-Provera)

Birth Control Pill

Foam

Contraceptive sponge

Norplant/IUD

Jelly or cream alone

Condom, rubber

Suppository or insert

Diaphragm

Rhythm

Other (explain):

NO YES

If yes:

Shots (Depo-Provera)

Birth Control Pill

Foam


Norplant/IUD


Condom, rubber

Suppository or insert

Diaphragm

Rhythm

Other (explain):


26/70



25. Do you have any special medical conditions that I should be aware of?

Mother: Father:

NO YES

If yes, explain:

Have you had any complications?

NO YES

If yes, specify:

NO YES

If yes, explain:

Have you had any complications?

NO YES

If yes, specify:

26. Are you taking any medicines? NO YES

If yes, name and list its purpose:

A lot of people smoke, use alcohol or other drugs as a way of dealing with their stress.

27. Does anyone smoke or use other types of tobacco who has regular contact with your baby?

NO YES

During

Pregnancy Prior to Pregnancy Comments

You

Partner/Spouse

Others

28. Does anyone drink alcohol who has regular contact with your baby? NO YES

During

Pregnancy Prior to Pregnancy Comments You

Partner/Spouse

Others


27/70



29. In the last month have you used any drugs not prescribed by a doctor?

Mother: Father:

NO YES

If yes, describe:

NO YES

If yes, describe:

Safety for you and your baby is very important to think about.

30. Have you ever been threatened by or afraid of a close family member or partner?

Mother: Father:

NO YES

If yes, explain:

NO YES

If yes, explain:

31. Did you or have you received any of the following services (past/present)?

Mother: Father:

P a s

t

P r e s e n

t

P a s

t

P r e s e n

t

AFDC

SSI

ET (Employment & Training)

Food stamps

EPSDT/Project Good Start

WIC

DSS/YPS

DMR Case Management

Adolescent Parenting Program

Subsidized Day Care/STPC

Pregnancy & Parenting Program

Community Nursing/VNA

MA. Family Center/Family Network

Other (Specify)

AFDC

SSI


Food stamps


WIC

DSS/YPS

DMR Case Management






Other (Specify)


28/70



CHILD DEVELOPMENT:

Its important with a new child in the home to have someone to talk with or one place to get help with a concern .

32. What concerns, if any, do you have about caring for a new baby?

Mother: Father:

33. Who would you go to if you had questions/worries about parenting?

Mother: Father:

Own motherOwn father

Own stepmother

Own stepfather

Other relatives

Babys father

Pediatrician

Friend(s)

Other heath professional

Grandparent

Child care provider

Partner/Spouse

Other (Specify):


Own stepmother

Own stepfather

Other relatives

Babys father

Pediatrician

Friend(s)


Grandparent

Child care provider

Partner/Spouse

Other (Specify):

RELATIONSHIPS:

Having a baby can affect any relationship, and things quickly change during pregnancy. Some people find it helpful

to talk to others that have been in the same situation.

34. Do you have any friends or family members who are pregnant or who have had a baby recently?

Mother: Father:

NO YES NO YES


29/70



35.

Mother: Father:

Describe your relationship with your babys

father (If partner is different than father of thebaby ask question again).

Describe your relationship with your babys

mother.

36.

Mother: Father:

How happy are you right now with your babys

father? (If partner is different than father of the

baby ask question again.)

Unhappy Mostly Mostly Happy

Unhappy Happy

1 2 3 4

Partner:


Unhappy Happy

1 2 3 4

How happy are you right now with your babys

mother?


Unhappy Happy

1 2 3 4


30/70



YOUR CHILDHOOD AND FAMILY HISTORY:

Everyones family influences them one way or another. Id like to get a sense of how you were raised.

37.

Mother: Father:

Where were you born?

US Other (specify)________________

If not US,

When did you arrive in the US?__________

With whom did you arrive? ____________

Do you have close family members in your

home country? NO YES


US Other (specify)________________

If not US,

When did you arrive in the US?__________

With whom did you arrive? ____________



38. Who raised you?

Mother: Father:

39. Are you in close touch with your family?

Mother: Father:

NO YES

If yes, who?

NO YES

If yes, who?


31/70



40. As a child were you.

Mother: Father:

Loved

Valued

Yelled at

Made to feel uncomfortable

Encouraged

Praised

Abused

Criticized

Hugged/kissed

Trusted

Spanked

Embarrassed

Loved

Valued

Yelled at


Encouraged

Praised

Abused

Criticized

Hugged/kissed

Trusted

Spanked

Embarrassed

41. What discipline methods did your family use?

Mother: Father:

Changing focus/re-direction

Time out

ThreatsRewards

Yelling

Withholding privileges

Encouragement

Physical punishment/spanking

Shaming/name-calling

Reinforce good behavior

Grounding

Other________________


Time out

ThreatsRewards

Yelling


Encouragement




Grounding

Other________________


32/70



42. Overall, were you happy growing up?

Mother: Father:


Unhappy Happy

1 2 3 4


Unhappy Happy

1 2 3 4

EDUCATION AND EMPLOYMENT:

Many parents find that new babies affect their lives in ways they might not expect. This often includes adjusting

their educational and job plans.

43. What are your plans for school after the baby is born?

Mother: Father:

NO YES Dont know NO YES Dont know

44. What would be your dream job?

Mother: Father:

WRAP UP:

45. Is there anything else you want to talk about now?

Mother: Father:

I know we've covered a lot today. I really appreciate all your time in talking with me. I look forward to seeing you

next time!


33/70

1 Prenatal Entry Guide Supplemental Information (PREG SI)

Copy double sided on pink paper 2001 MA Chi ldrens Trust Fund/HF

Participants in Interview:____________________ Interviewer:__________________

1. Babys Name:________________________ Date completed:____/_____/____ 2. Delivery Date: ________________________ 3. Age: ________________________________

PARTICIPANT INFORMATION: (Father participant information on reverse.)


8. Have there been any major changes in the following since your baby was born?

If yes, please explain.

Mother: Father:

NO YES

Financial Arrangements

Own Health

Smoking/Drug Use

Education and Employment

Other

NO YES

Financial Arrangements

Own Health

Smoking/Drug Use

Education and Employment

Other


34/70






35/70



PREGNANCY EXPERIENCE:

9. Did you feel like you knew what to expect during pregnancy, and labor and delivery?

Mother:

NO YESIf no, explain:

Father:

NO YESIf no, explain:

HAVING A NEW BABY:

Having a new baby is a big deal for everyone, often full of excitement, change and surprises.

10. What are your memories of seeing your baby?Mother: Father:

11. Describe your baby. Is he/she what you expected?

Mother: Father:

12. What have you already learned about your baby?

Mother: Father:


36/70



13. What have you learned about yourself as a parent since your baby was born?

Mother: Father:

CHILD CARE AND DEVELOPMENT:

14. Who takes care of the baby?

Mother: Father:

15. How are you feeding the baby now? Formula Breast Combination

16. How is it going?

17. What do you do to comfort your baby?

Mother: Father:

Feed your baby

Put your baby in crib

Hold your baby

Nothing seems to work when your babys

crying

Sing to your baby

Rock your baby

Other (describe) ____________

Feed your baby


Hold your baby

Nothing seems to work when you r babys

crying

Sing to your baby

Rock your baby


18. What works the best?

Mother: Father:


37/70



New parents often like to think ahead to when their child will learn exciting new skills.

19. When do you think your baby will:

Mother: Father:

Crawl? _______________

Eat Solid Foods?________Walk? _______________

Talk?_________________

Smile?________________

Toilet Train?___________

Crawl? _______________

Eat Solid Foods?________Walk? _______________

Talk?_________________

Smile?________________


PARENTAL SUPPORT/RELATIONSHIPS:

20. Now that you are a parent, what do you like:Mother: Father:

the best?

the least?

the best?

the least?

21.

Mother: Father:

Describe your relationship with your babys father

(If partner is different than father of the baby ask

again).

Describe your relationship with your babys mother.


38/70



Its important with a new ch ild in the home to have someone to talk with or one place to get help with a concern.

22. What have been the reactions of your family and friends to your baby?

Mother: Father:

23. Have you noticed changes in your partners outlook or behavior since your baby was born?

Mother: Father:

24. What concerns, if any, do you have about your baby?

Mother: Father:

YOU AND YOUR FAMILYS HEALTH:

Baby:

25. Have you chosen a pediatrician for your baby? NO YES

If yes, contact info:

NAME:

ADDRESS:

PHONE:

Last appointment: ____________ Nature of visit_________________________________

Next appointment ____________


39/70



26. Are you satisfied with the care you are receiving? NO YES

If no, explain:

27. Do you feel comfortable asking your doctor questions when you may not understand what he/she

said?

NO YES

28. Does your baby have health insurance? NO YES

If yes, name of insurance:

29. Has your baby had any illness, injury or health problem since birth? NO YES

If yes, describe:

30. Did you see a medical provider for this issue? NO YES

If no, why not?

31. How is your babys health now?

32. Are you receiving early intervention services for your baby? NO YES

If yes, describe:

Parent(s):



40/70



34. Are you currently using birth control?

Mother: Father:

NO YES

If yes:

Shots (Depo-Provera)Foam

Birth Control Pills

Norplant/IUD


Condom, rubber

Diaphragm


Rhythm

Suppository or insertOther (explain):

NO YES

If yes:

Shots (Depo-Provera)Foam

Birth Control Pills

Norplant/IUD


Condom, rubber

Diaphragm


Rhythm

Suppository or insertOther (explain):

35. Any questions or concerns about this method? NO YES

Mother: Father:

Safety for you and the baby is very important to think about.

36. Have you ever been concerned about your own or your childs safety?

Mother: Father:

NO YES

If yes, explain:

NO YES

If yes, explain:


41/70



37. Have you ever been threatened by or afraid of a family member or partner?

Mother: Father:

NO YES

If yes, explain:

NO YES

If yes, explain:

38. Do you receive any of the following services now?

Mother: Father:

AFDCSSI


Food stamps


WIC

Growth & Nutrition (FTT)

DSS

DMR Case Management

Adolescent Parenting PrgSubsidized Day Care

Preg & Parenting Prg


Early Intervention

Other (Specify)

AFDCSSI


Food stamps


WIC


DSS

DMR Case Management

Adolescent Parenting PrgSubsidized Day Care

Preg & Parenting Prg


Early Intervention

Other (Specify)


42/70

1 Postpartum Form (PPF)

Copy double sided on yellow paper 2001 MA Childrens Trust Fund/HF

Name of Interviewer:_____________________________ Date started: ____/____/____

Participant(s) in interview: _________________________ Date completed: ____/____/____

__________________________________________________________________________________

PARTICIPANT INFORMATION: (Father participant information on back)

1. Name: __________________________________________________ 2. DOB: ____________ 3. Address: _____________________________________________________________________

4. Phone: _____________________________ 5. Delivery Date: _________________________

6. Babys name: ________________________ 7. Babys age: ____________________________

HOME ENVIRONMENT:


Mother: Father:Have own drivers license

Walk

Have own car


Family transport


Friends transport



Walk

Have own car


Family transport


Friends transport



Mother:

NO YES

If no, explain:

Father:

NO YES

If no, explain:

PREGNANCY EXPERIENCE: 10. Did you feel like you knew what to expect during pregnancy, labor and delivery?

Mother:

NO YES

If no, explain:

Father:

NO YES

If no, explain:


43/70




1. Name: __________________________________________________ 2. DOB: ____________ 3. Address: ___________________________________________________________________

4. Phone: _____________________________


44/70



HAVING A NEW BABY:

Having a new baby is a big deal for everyone, often full of excitement, change and surprises.

11. What are your memories of seeing your baby?

Mother: Father:

12. Describe your baby. Is he/she what you expected?

Mother: Father:

13. What have you already learned about your baby?

Mother: Father:

14. What have you learned about yourself as a parent since your baby was born?

Mother: Father:


45/70



CHILD CARE AND DEVELOPMENT:

15. Who takes care of the baby?

Mother: Father:

16. How are you feeding the baby now? Formula Breast Combination

17. How is it going?

18. What do you do to comfort your baby?

Mother: Father:

Feed your baby


Hold your baby


crying

Sing to your baby

Rock your baby


Feed your baby


Hold your baby


crying

Sing to your baby

Rock your baby


19. What works the best?

Mother: Father:


46/70



New parents often like to think ahead to when their child will learn exciting new skills.

20. When do you think your baby will:

Mother: Father:

Crawl? _______________

Eat Solid Foods?________

Walk? _______________

Talk?_________________

Smile?________________


Crawl? _______________

Eat Solid Foods?________

Walk? _______________

Talk?_________________

Smile?________________


21. Now that you are a parent, what do you like:

Mother: Father:

the best?

the least?

the best?

the least?

Its important with a new child in the ho me to have someone to talk with or one place to get help with a concern.

22. What have been the reactions of your family and friends to your baby?

Mother: Father:

23. Have you noticed changes in your partners outlook or behavior since your baby w as born?

Mother: Father:

24. What concerns, if any, do you have about your baby?


47/70



Mother: Father:

25. Where would you go if you had questions/worries about parenting?

Mother: Father:

Own mother

Own father

Own stepmother

Own stepfather

Other relatives

Babys father

Pediatrician

Friend(s)


Grandparent

Child care provider

Partner/Spouse

Other (Specify):

Own mother

Own father

Own stepmother

Own stepfather

Other relatives

Babys mother

Pediatrician

Friend(s)


Grandparent

Child care provider

Partner/Spouse

Other (Specify):

YOU AND YOUR FAMILYS HEALTH:

Baby:

26. Have you chosen a pediatrician for your baby? NO YES

If yes, contact info:

NAME:

ADDRESS:

PHONE:



27. Are you satisfied with the care you are receiving?


48/70



Mother:

NO YES

If no, explain:

Father:

NO YES

If no, explain:


said?

NO YES

29. Does your baby have health insurance? NO YES

If yes, name of insurance:

30. Has your baby had any illness, injury or health problem since birth? NO YES

If yes, describe:


If no, why not?


33. Are you receiving early intervention services for your baby? NO YES

If yes, describe:

Parent(s):


49/70



34. Do you have any special medical conditions that I should be aware of? NO YES

If yes, explain:

Mother: Father:

35. Are you satisfied with the health care you are receiving?

Mother: Father:

NO YES

If no, explain:

NO YES

If no, explain:

36. When was your last doctors appointment?


38. What are your eating habits/appetite like??

39. Are you taking any medicines?

Mother:

NO YES

If yes, name and list its purpose for both

prescription and over the counter:

Father:

NO YES

If yes, name and list its purpose for both

prescription and over the counter:

40. Are you currently using birth control? NO YES


50/70



If yes:

Shots (Depo-Provera) Foam

Birth Control Pills Norplant/IUD

Jelly or cream alone Condom, rubber

Diaphragm Contraceptive sponge

Rhythm Suppository or insert

Other (explain):

41. Any questions or concerns about this method?

Mother:

NO YES

Father:

NO YES

A lot of people smoke, use alcohol or other drugs as a way of dealing with their stress.

42. Does anyone smoke or use other types of tobacco who has regular contact with your baby?

NO YES

# Smoked in

past month?

Smoked during

your pregnancy?

(check if yes)

Comments

You

Partner/Spouse

Others

43. Does anyone drink alcohol who has regular contact with your baby? NO YES

# Days in the

past month?

Drank during

your pregnancy?

(check if yes)

Comments

You

Partner/Spouse

Others


51/70



44. In the last month have you used any drugs not prescribed by a doctor?

Mother:

NO YES

If yes, describe:

Father:

NO YES

If yes, describe:

Safety for you and the baby is very important to think about.

45. Have you ever been concerned about your own or your childs safety?

Mother:NO YES

If yes, explain:

Father:NO YES

If yes, explain:

46. Have you ever been threatened by or afraid of a close family member or partner?

Mother:

NO YES

If yes, explain:

Father:

NO YES

If yes, explain:



52/70



Mother: Father:

P a s

t

P r e s e n

t

P a s

t

P r e s e n

t

AFDCSSI


Food stamps


WIC


DSS/YPS

DMR Case Management





Early Intervention


Other (Specify)

AFDCSSI


Food stamps


WIC


DSS/YPS

DMR Case Management





Early Intervention


Other (Specify)

RELATIONSHIPS:

Babies can affect any relationship, and things can change quickly after the birth of a baby. Some people find it

helpful to talk to others that have been in the same situation.

48. Do you have any friends or family members who are pregnant or who have had a baby recently?

Mother:

NO YES

Father:

NO YES

49.


53/70



Mother: Father:

Describe your relationship with your babys fathe r

(If partner is different than father of the baby ask

again).

Describe your relationship with your babys mother.

50.

Mother: Father:

How happy are you right now with this

relationship? (If partner is different than father of

the baby ask again.)


Unhappy Happy

1 2 3 4

Partner:


Unhappy Happy

1 2 3 4

How happy are you right now with this relationship?


Unhappy Happy

1 2 3 4

YOUR CHILDHOOD AND FAMILY HISTORY:

Everyones family influences them one way or another. Id like to get a sense of how you were raised.

51.

Mother: Father:


US Other (specify)_________

If not US:

When did you arrive in the US?____________

With whom did you arrive? _______________




US Other (specify)_________

If not US:

When did you arrive in the US?____________

With whom did you arrive? _______________



52. Who raised you?


54/70



Mother: Father:

53. Are you in close touch with your family?

Mother:

NO YES

If yes, who?

Father:

NO YES

If yes, who?

54. As a child were you.

Mother: Father:

Loved

ValuedYelled at


Encouraged

Praised

Abused

Criticized

Hugged/kissed

Trusted

Spanked

Embarrassed

Loved

ValuedYelled at


Encouraged

Praised

Abused

Criticized

Hugged/kissed

Trusted

Spanked

Embarrassed

55. What discipline methods did your family use?


55/70



Mother: Father:


Time out

Threats

Rewards

Yelling


Encouragement




Grounding

Other________________


Time out

Threats

Rewards

Yelling


Encouragement




Grounding

Other________________

56. Overall, were you happy growing up?

Mother:


Unhappy Happy

1 2 3 4

Father:


Unhappy Happy

1 2 3 4

57. What would you do the same as your parents in raising your own child?

Mother: Father:

58. What would you do different from your parents in raising your own child?

Mother: Father:

EDUCATION AND EMPLOYMENT:


56/70



Many parents find that new babies affect their lives in ways they might not expect. This often includes adjusting

their educational and job plans.

59. Do you have plans for education?

Mother:

NO YES Dont know If yes, what school?

Father:

NO YES Dont know If yes, what school?

60. What would be your dream job?

Mother: Father:

WRAP UP


Mother: Father:

I know weve covered a lot today. I really a ppreciate all your time in talking with me. I look forward to seeing you

and the baby next time!


57/70

1 Participant Transfer Form (PTF)

Copy double sided on lavender paper. 2004 MA Childrens Trust Fund/HF

PARTICIPANT INFORMATION: (Other participant information on back)

1. Name: __________________________________________________ 2. DOB: ____________ 3. Address: _____________________________________________________________________

4. Phone: _____________________________

5. Babys name: ________________________ 6. Babys age (or EDC): __________________

AT YOUR PREVIOUS HEALTHY FAMILIES PROGRAM:

Healthy Families programs offer similar services across the state, but each program has its own personality.

Learning from you about your past experience in Healthy Families can help me to be more effective in meeting your

needs.

7. What kind of services did you participate in at your previous Healthy Families program?

Mother: Father:

8. What did you like about the services?

Mother: Father:

9. If you had the opportunity to run the Healthy Families program, what would you keep the same?

Mother: Father:

10. If you had the opportunity to run the Healthy Families program, what would you change?

Mother: Father:


58/70




11. Name: __________________________________________________ 1 2. DOB: ____________ 13. Address: ___________________________________________________________________

14. Phone: _____________________________


59/70



HOME ENVIRONMENT:

Moving from one town to another can bring about many changes. Learning about what has changed for your family

will be helpful in making sure you have the best services possible.

15. Can you tell me about the reasons you moved here?

Mother: Father:

16. Who lives with you now?Mother: Father:


Mother:

NO YES

If no, explain:

Father:

NO YES

If no, explain:


Mother: Father:


Walk

Have own car


Family transport


Friends transport



Walk

Have own car


Family transport


Friends transport



60/70



19. With your recent move, who takes care of the baby?

Mother: Father:

SOCIAL SUPPORT:

20. With your recent move, do you have any friends or family members with children around the same age as

yours in your new community?

Mother:

NO YES

Father:

NO YES

21. Given your recent move, are you in close touch with your family?

Mother:

NO YES

If yes, who?

Father:

NO YES

If yes, who?

22. With your recent move, where would you go if you had questions/worries about parenting?

Mother: Father:


Own stepmother

Own stepfather

Other relatives

Babys father

Pediatrician

Friend(s)


Grandparent

Child care provider

Partner/Spouse

Other (Specify):


Own stepmother

Own stepfather

Other relatives

Babys mother

Pediatrician

Friend(s)


Grandparent

Child care provider

Partner/Spouse

Other (Specify):


61/70




Mother: Father:

P a s

t

P r e s e n

t

P a s

t

P r e s e n

t

TANF/DTA

TLP/DTA

YPP/DTA

ET (Employment & Training)/DTA

Food stamps /DTA

FOR Families/DPH

WIC/DPH

Early Intervention/DPH

Healthy Start/DPH

Subsidized Day Care (STPC)/OCCS

MA Family Center/Family Network

(CTF/DOE)

YPS/DSS

DSS for yourself

DSS for your baby


Case Management/DMR

Case Management/DMH





Parent Aide

Mental Health services

Other (Specify)

TANF/DTA

TLP/DTA

YPP/DTA

ET (Employment & Training)/DTA

Food stamps /DTA

FOR Families/DPH

WIC/DPH

Early Intervention/DPH

Subsidized Day Care (STPC)/OCCS

MA Family Center/Family Network

(CTF/DOE)

DSS/YPS

DSS for yourself

DSS for your baby

Case Management/DMR

Case Management/DMH






Parent Aide

Mental Health services

Other (Specify)

24. If you want to continue with these services, do you need assistance in securing them now that you have

moved?


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Have there been any major changes in the following since your move?

25. Financial arrangements?

Mother: Father:

26. Education and/or Employment?

Mother: Father:

27. Smoking/drug use? Mother: Father:

28. Other

Mother: Father:


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YOU AND YOUR FAM ILYS HEALTH:

Baby:

29. Have you chosen a different pediatrician for your baby? NO YES

IF YES,

CONTACT INFO:

NAME:

ADDRESS:

PHONE:



30. Are you satisfied with the care your baby is receiving?

Mother:

NO YES

If no, explain:

Father:

NO YES

If no, explain:


said?NO YES

Health professional recommend that children ages two and older have a dentist.

32. Do you have dental care provider for your baby?

IF YES,

CONTACT INFO:

NAME:

ADDRESS:

PHONE:




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33. Has your baby had any illness, injury or health problem since your move? NO YES

If yes, describe:


35. If no, why not?


PARENT:

37. Do you have a different primary care provider?

IF YES,

CONTACT INFO:

NAME:

ADDRESS:

PHONE:



Mother: Father:

NO YES

If no, explain:

NO YES

If no, explain:

38. Are you satisfied with the health care you are receiving?

Mother: Father:

NO YES

If no, explain:

NO YES

If no, explain:


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39. Have you had any illness, injury or health problem since your move? NO YES

If yes, describe:

Mother: Father:

NO YES

If no, explain:

NO YES

If no, explain:


41. If no, why not?

Mother: Father:

NO YES

If no, explain:

NO YES

If no, explain:

42. How is your health now?

Mother: Father:

WRAP UP

43. What can I do to make the transition from your previous HF program easier for you and your family?

Mother: Father:


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44. What expectations do you have for me as your home visitor?

Mother: Father:


Mother: Father:

I know weve covered a lot. I really appreciate all your time in talking with me. I look forward to seeing you and

the baby next time!


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Family Profile Summary Sheet

Mother of child: _____________________ Father of child: _____________________ Child or EDC: _____________________________

Parent Identified Staff Identified

Strengths/Accomplishments

__________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________

Challenges/Needs

__________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________

Assessment Summary (Familys Story)

______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ Curriculum/Resources Recommended:(These are based on the familys comments and your observations)


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______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________

Next Steps: (Potential goals for IFSP process) ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ___

Documents

H Standardized Assessment and Information Gathering Policy