South Carolina Association of Community Action Partnerships

Early Head Start Child Care Partnerships

Parent Conference/Home Visit Form

Parent Conference

Home Visit (For Center Based Only)

Initial

Date:

Child's Last Name: *

Child's First Name: *

Child's Middle Name:

Parent's Last Name: *

Parent's First Name: *

Parent's Middle Name:

Teacher's Name: *

Site/Room: *

Center: *

1. Health, Nutrition, and Child Safety

In each below, briefly describe parent comments and/or concerns regarding the following topics

Pedestrian Safety Is parent aware of child pedestrian safety practices?	Reminder of parking lot safety: car seat laws, parking at site, etc.
Health Describe your child's health and/or changes/concerns.	Changes in daily routine: Care Plans, physical/shots updated, etc.
Nutrition Describe your child's eating habits and any new allergies or concerns.	Changes in diet: foods they like/dislike, Medical Statements changes, etc.

2. Education

5 essential domains of ELOF document strengths, challenges, goals working on, and share photo s/work

Transition IN or OUT of Early Head Start Not Applicable at this time	Follow transition policies: is this the child's first time in school, etc.?
1. Approaches to Learning
2. Social and Emotional Development
3. Language and Literacy
4. Cognition (Cognitive Development)
5. Perceptual Motor and Physical Development
Individualization; Screenings and Assessments	Go over ASQ scores/ summary sheet: progress made, ILP/IFSP goals developed/followed up on, TSG Checkpoints, etc.

3. Disabilities Services

In each cell below, briefly describe parent comments and/or concerns regarding the following topics

No IFSP No Concerns	Do you have concerns about your child’s development?
Child does have a current IFSP	Are the services stated in the IFSP constant and ongoing? If no, why?
Referral Made Date:	Has a disabilities referral been initiated with BabyNet or the local education agency (LEA)? Follow up on referral (assessment dates; progress of parent in process; etc.):

4. Behavioral

Briefly describe parent comments and/or concerns regarding the following topics if applicable

Social and Emotional Development No Concerns	Behavior management concerns: strategies, resources needed/given, family issues/ concerns, etc.
Referral Made Date:	Follow up on referral: current services, progress on behavior, etc.

5. Family and Community Engagement

In each cell below, briefly describe parent comments and/or concerns regarding the following topics

Family Partnership Agreement Before 90th Day, No Goals	Changes, immediate urgencies, support/resources needed, follow up on goals.
Family Literacy and at Home Learning Activities	How often do you read to your child? Follow up on at Home Learning Activities.
Case Management Needed	Issues that need to be addressed: absences, late drop off/pick up issues, etc.

Additional Notes:

I confirm that I have read and understand this form. *

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Signature required

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Parent Signature

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