Family_Partnership_Agreement___EHS by stariya

VIEWS: 18 PAGES: 26

									                                                Early Head Start
                                          Family Partnership Agreement
Child’s Name:                                                                                        Entry Date:
Parent’s / Guardian’s Name:                                                                          DOB:
**************************************************************************************************************************************
SHARED FAMILY INFORMATION:
                                                         First Year                  Second Year              Third Year               Fourth Year
Teacher/FSA/HV also working with the
family:
Siblings Enrolled in Other Option:
Family Goal Manager is:
Copy of FPA Provided at End of Year:                    YES       NO               YES    NO                  YES         NO           YES        NO

PARENT TRANING DATES:
                                                      1st Year                      2nd Year                3rd Year               4th Year
 Orientation & Volunteer
 Pedestrian & Transportation


ASQ-SE SCREENING: (1st Screening within 45 days, every six months thereafter)

            (Date)            No Concerns (Under Cut-off)                           See ASQ-SE, Staffings (Above Cut-off)
            (Date)            No Concerns (Under Cut-off)                           See ASQ-SE, Staffings (Above Cut-off)
            (Date)            No Concerns (Under Cut-off)                           See ASQ-SE, Staffings (Above Cut-off)
            (Date)            No Concerns (Under Cut-off)                           See ASQ-SE, Staffings (Above Cut-off)
            (Date)            No Concerns (Under Cut-off)                           See ASQ-SE, Staffings (Above Cut-off)
            (Date)            No Concerns (Under Cut-off)                           See ASQ-SE, Staffings (Above Cut-off)
            (Date)            No Concerns (Under Cut-off)                           See ASQ-SE, Staffings (Above Cut-off)
            (Date)            No Concerns (Under Cut-off)                           See ASQ-SE, Staffings (Above Cut-off)
            (Date)            No Concerns (Under Cut-off)                           See ASQ-SE, Staffings (Above Cut-off)

WELL CHILD & DENTAL EXAMS: (GOAL required if not completed within timeframe)
  Write in date appointment is due in (). Check box when appointment is completed. If child’s physician does not perform, write NA on Due Date.

  Newborn Check                              2 Week- Dr. (               )                     2 Week- EHS/PH (                    )
  4 Months (                  )              6 Months (                  )                     9 Months (                          )
  12 Months (                 )              15 Months (                 )                     18 Months (                         )
  2 Year (                    )              3 Year (                        )

 THREE YEAR OLDS ONLY
  Dental Exam Completed                 Follow-Up Required:            NO               YES (GOAL)


                   (Month/Year) Six Months Before Child’s 3rd Birthday Transition Begins.

     Permission To Forward Records (Multi Agency Release)
     Discussed Child/Family/Childcare Needs & Options
     Three Year Old Screening Options Discussed
     Visited & Registered
     Transition Packet Given To Family
     Transition Process Reviewed W/Family
          Comments:

P:\Forms\Family Partnership Agreement-EHS                                                                        (7/07)                                1
                                             ENTRY INTO PROGRAM
                                   All Info. On Application Must Have Written Clarification
                                                 NA=Does not apply to family


                                                                                                   Address Later      No
Application For Enrollment Information                                            NA      Goal       (Date To)       Goal
English Language Learner (Specify in goal if family requests written translation and/or verbal translator services)
   Primary Language                                                                               (          ) 

Family Type (Co-Parenting, Parent Involvement (P/T, HV, Class) Reunification Plan, Sending Info, Support Grp)
   Non-Residential Parent                                                                    (            )           
    Foster Care                                                                                     (         )       
    Grandparents Primary Guardian                                                                   (         )       

Child Concerns (Referral, Screening, Collaboration Goals- DFS, IEP/IFSP, Childcare, Mental Health, Physician)
    Developmental/IEP/IFSP/Physical Health                                                   (            )
 Mental Health/Behavior/Attention Span                                                             (         )
    Childcare Collaboration                                                                         (         )       


Family Concerns (Referral, Collaboration, Support Group, Counseling, Education Goal/ELL, WIC, EHS)
   Family Education / Literacy                                                             (                  )
    Mental/Physical Health Concerns                                                                 (         )       
    Recent Separation/Marriage/Divorce                                                              (         )       
 Job Loss or Change                                                                                (         )       
    Moved/Eviction/Homeless                                                                         (         )       
 Incarceration/Court Mandated/Legal                                                                (         )       
 Death of a Family Member                                                                          (         )       
    Change In The Number Of Children                                                                (         )       
    DFS Case Plan                                                                                   (         )
 Treatment/Counseling for Substance Abuse                                                          (         )
    Pre-existing Family / Case Plan With Other Agencies                                             (         )


Medical/Dental Home (Referral, Kid Care, Title 19, Sliding Fee Services, etc.)
    Doctor:                                 Dentist:                                 No Goal=Have Providers
    Prenatal / Post-Partum Physician:           Goal Required=No Dr/Dentist


 Information Provided To Child/Family Regularly: Resource Guide, Parent & Child Magazine (Every Other Month),
 Monthly Center Newsletter, Monthly Parent Meeting Flyers, Male/Father Involvement Flyers, Training Opportunity Flyers,
 Community Event Notices, etc. {File Located On Site}




P:\Forms\Family Partnership Agreement-EHS                                                     (7/07)                          2
First Year of Enrollment                                 Complete in Oct & April (Underline indicates Priority Goal)
                                        Health & Safety Information / Goals
 Safety Checklist For Our Home / Gun Safety                          Poison Info (Hotline #, Poisons At Home)
 Stop Smoking / Smokeless Tobacco Information                        Smoke Alarm For Our Home
First Aid / CPR Training
 (Circle) Allergies, Anemia, Asthma, Ear Infections, Dental Care, Healthy Foods, Lice, SIDS
Identified Strengths:
 Medical Coverage – Child(ren)                Medical Coverage - Adults                Aware of Sliding Fee Providers
 Guns Safely Locked Away                      Poison Info By Phone                     Child(ren) on WIC
 Working Smoke Alarms                         Trained in CPR/First Aid                 Safety Checklists Completed
 Have Family Doctor                           Child Has Physical / WCC                 Physical Follow-Up Completed
 Have Family Dentist                          Child Has Dental Exam                    Dental Follow-Up Completed
                                      Child Development Information / Goals
 Ideas To Develop Early Reading Skills                              Setting Limits / Discipline
 Sharing Info=Childcare & EHS/HS                                    Improving My Child’s Self-Esteem
 (Circle) Anger, Bedtime/Daily Routines, Depression, Being Disrespectful, Fears, Lying, Sibling Relations, Self-Help
   Skills, Thumb Sucking, Violence
Identified Strengths:
 Attends Parent Group Trainings        Do In-Kind Activities                    Enrolled in HS/EHS Before
 Participates in Home Visits           Participates in P/T Conf                 Attends IEP/IFSP Meetings
 Has Attended Parenting Classes        Use Consistent Routines                  Read Parent/Child Magazines
 Attends Fatherhood Activities         Working Toward/Has CDA                   Attend Child Develop. Class
                            Personal & Family Development Information / Goals
 Finding A Job / Employment Opportunities                           Unemployment / SSI / SSDI Information
 Family Activities To Help My Child Learn                           Budgeting / Credit Counseling
 Adult Ed: High School, ELL, GED, College                           Counseling / Having Someone To Talk To
 Determining If I’m In A Healthy Relationship                       Strengthening My Relationship / Marriage
 (Circle) Raising My Grandchild, Co-Parenting, Sharing Custody, Father Involvement
Identified Strengths:
 Parent(s) Working                     Attend ELL/GED/High School             Attend College
 Receiving SSI/SSDI                    Good Co-Parenting Relations            Non-Residential Parent Active
 Use Family Budget                     Quality Family Time Together           Strong Support System
 Child In Counseling                   Family Attends Counseling              Attend Marriage Counseling
                                Housing & Transportation Information / Goals
 Assistance Finding Housing                                       Getting A Car Seat
 Help With Utilities / Weatherization                             Help Installing A Car Seat
 Help With Transportation (Child to/from center)                  Help With Transportation (Appointments)
Identified Strengths:
 Receiving LIEAP                     Housing Meets Family Needs       Bussing Provided By HS/EHS
 Able To Pay Own Heating             Receive Subsidized Housing       Family Has Vehicle(s)
 Home Is Winterized                  Children Have Own Bedrooms       Family Has Appropriate Car Seat(s)

Information Provided:                       Date Given     Follow-Up Date    Follow-Up:
1.                                                                          No Further Questions     More Info Requested
2.                                                                          No Further Questions     More Info Requested
3.                                                                          No Further Questions     More Info Requested
4.                                                                          No Further Questions     More Info Requested
5.                                                                          No Further Questions     More Info Requested
6.                                                                          No Further Questions     More Info Requested
7.                                                                          No Further Questions     More Info Requested
8.                                                                          No Further Questions     More Info Requested

P:\Forms\Family Partnership Agreement-EHS                                                     (7/07)                       3
Second Year of Enrollment                                Complete in Oct & April (Underline indicates Priority Goal)
                                        Health & Safety Information / Goals
 Safety Checklist For Our Home / Gun Safety                          Poison Info (Hotline #, Poisons At Home)
 Stop Smoking / Smokeless Tobacco Information                        Smoke Alarm For Our Home
 First Aid / CPR Training
 (Circle) Allergies, Anemia, Asthma, Ear Infections, Dental Care, Healthy Foods, Lice, SIDS
Identified Strengths:
 Medical Coverage – Child(ren)         Medical Coverage - Adults                Aware of Sliding Fee Providers
 Guns Safely Locked Away               Poison Info By Phone                     Child(ren) on WIC
 Working Smoke Alarms                  Trained in CPR/First Aid                 Safety Checklists Completed
 Have Family Doctor                    Child Has Physical / WCC                 Physical Follow-Up Completed
 Have Family Dentist                   Child Has Dental Exam                    Dental Follow-Up Completed
                                      Child Development Information / Goals
 Ideas To Develop Early Reading Skills                              Setting Limits / Discipline
 Sharing Info=Childcare & EHS/HS                                    Improving My Child’s Self-Esteem
 (Circle) Anger, Bedtime/Daily Routines, Depression, Being Disrespectful, Fears, Lying, Sibling Relations, Self-Help
   Skills, Thumb Sucking, Violence
Identified Strengths:
 Attends Parent Group Trainings        Do In-Kind Activities                    Enrolled in HS/EHS Before
 Participates in Home Visits           Participates in P/T Conf                 Attends IEP/IFSP Meetings
 Has Attended Parenting Classes        Use Consistent Routines                  Read Parent/Child Magazines
 Attends Fatherhood Activities         Working Toward/Has CDA                   Attend Child Develop. Class
                            Personal & Family Development Information / Goals
 Finding A Job / Employment Opportunities                           Unemployment / SSI / SSDI Information
 Family Activities To Help My Child Learn                           Budgeting / Credit Counseling
 Adult Ed: High School, ELL, GED, College                           Counseling / Having Someone To Talk To
 Determining If I’m In A Healthy Relationship                       Strengthening My Relationship / Marriage
 (Circle) Raising My Grandchild, Co-Parenting, Sharing Custody, Father Involvement
Identified Strengths:
 Parent(s) Working                     Attend ELL/GED/High School             Attend College
 Receiving SSI/SSDI                    Good Co-Parenting Relations            Non-Residential Parent Active
 Use Family Budget                     Quality Family Time Together           Strong Support System
 Child In Counseling                   Family Attends Counseling              Attend Marriage Counseling
                                Housing & Transportation Information / Goals
 Assistance Finding Housing                                       Getting A Car Seat
 Help With Utilities / Weatherization                             Help Installing A Car Seat
 Help With Transportation (Child to/from center)                  Help With Transportation (Appointments)
Identified Strengths:
 Receiving LIEAP                     Housing Meets Family Needs       Bussing Provided By HS/EHS
 Able To Pay Own Heating             Receive Subsidized Housing       Family Has Vehicle(s)
 Home Is Winterized                  Children Have Own Bedrooms       Family Has Appropriate Car Seat(s)

Information Provided:                       Date Given    Follow-Up Date     Follow-Up:
1.                                                                          No Further Questions   More Info Requested
2.                                                                          No Further Questions   More Info Requested
3.                                                                          No Further Questions   More Info Requested
4.                                                                          No Further Questions   More Info Requested
5.                                                                          No Further Questions   More Info Requested
6.                                                                          No Further Questions   More Info Requested
7.                                                                          No Further Questions   More Info Requested
8.                                                                          No Further Questions   More Info Requested


P:\Forms\Family Partnership Agreement-EHS                                                   (7/07)                      4
Third Year of Enrollment                                 Complete in Oct & April (Underline indicates Priority Goal)
                                        Health & Safety Information / Goals
 Safety Checklist For Our Home / Gun Safety                          Poison Info (Hotline #, Poisons At Home)
 Stop Smoking / Smokeless Tobacco Information                        Smoke Alarm For Our Home
 First Aid / CPR Training
 (Circle) Allergies, Anemia, Asthma, Ear Infections, Dental Care, Healthy Foods, Lice, SIDS
Identified Strengths:
 Medical Coverage – Child(ren)         Medical Coverage - Adults                Aware of Sliding Fee Providers
 Guns Safely Locked Away               Poison Info By Phone                     Child(ren) on WIC
 Working Smoke Alarms                  Trained in CPR/First Aid                 Safety Checklists Completed
 Have Family Doctor                    Child Has Physical / WCC                 Physical Follow-Up Completed
 Have Family Dentist                   Child Has Dental Exam                    Dental Follow-Up Completed
                                      Child Development Information / Goals
 Ideas To Develop Early Reading Skills                              Setting Limits / Discipline
 Sharing Info=Childcare & EHS/HS                                    Improving My Child’s Self-Esteem
 (Circle) Anger, Bedtime/Daily Routines, Depression, Being Disrespectful, Fears, Lying, Sibling Relations, Self-Help
   Skills, Thumb Sucking, Violence
Identified Strengths:
 Attends Parent Group Trainings        Do In-Kind Activities                    Enrolled in HS/EHS Before
 Participates in Home Visits           Participates in P/T Conf                 Attends IEP/IFSP Meetings
 Has Attended Parenting Classes        Use Consistent Routines                  Read Parent/Child Magazines
 Attends Fatherhood Activities         Working Toward/Has CDA                   Attend Child Develop. Class
                            Personal & Family Development Information / Goals
 Finding A Job / Employment Opportunities                           Unemployment / SSI / SSDI Information
 Family Activities To Help My Child Learn                           Budgeting / Credit Counseling
 Adult Ed: High School, ELL, GED, College                           Counseling / Having Someone To Talk To
 Determining If I’m In A Healthy Relationship                       Strengthening My Relationship / Marriage
 (Circle) Raising My Grandchild, Co-Parenting, Sharing Custody, Father Involvement
Identified Strengths:
 Parent(s) Working                     Attend ELL/GED/High School             Attend College
 Receiving SSI/SSDI                    Good Co-Parenting Relations            Non-Residential Parent Active
 Use Family Budget                     Quality Family Time Together           Strong Support System
 Child In Counseling                   Family Attends Counseling              Attend Marriage Counseling
                                Housing & Transportation Information / Goals
 Assistance Finding Housing                                       Getting A Car Seat
 Help With Utilities / Weatherization                             Help Installing A Car Seat
 Help With Transportation (Child to/from center)                  Help With Transportation (Appointments)
Identified Strengths:
 Receiving LIEAP                     Housing Meets Family Needs       Bussing Provided By HS/EHS
 Able To Pay Own Heating             Receive Subsidized Housing       Family Has Vehicle(s)
 Home Is Winterized                  Children Have Own Bedrooms       Family Has Appropriate Car Seat(s)

Information Provided:                       Date Given    Follow-Up Date     Follow-Up:
1.                                                                          No Further Questions   More Info Requested
2.                                                                          No Further Questions   More Info Requested
3.                                                                          No Further Questions   More Info Requested
4.                                                                          No Further Questions   More Info Requested
5.                                                                          No Further Questions   More Info Requested
6.                                                                          No Further Questions   More Info Requested
7.                                                                          No Further Questions   More Info Requested
8.                                                                          No Further Questions   More Info Requested


P:\Forms\Family Partnership Agreement-EHS                                                   (7/07)                      5
Fourth Year of Enrollment                                Complete in Oct & April (Underline indicates Priority Goal)
                                        Health & Safety Information / Goals
 Safety Checklist For Our Home / Gun Safety                          Poison Info (Hotline #, Poisons At Home)
 Stop Smoking / Smokeless Tobacco Information                        Smoke Alarm For Our Home
 First Aid / CPR Training
 (Circle) Allergies, Anemia, Asthma, Ear Infections, Dental Care, Healthy Foods, Lice, SIDS
Identified Strengths:
 Medical Coverage – Child(ren)         Medical Coverage - Adults                Aware of Sliding Fee Providers
 Guns Safely Locked Away               Poison Info By Phone                     Child(ren) on WIC
 Working Smoke Alarms                  Trained in CPR/First Aid                 Safety Checklists Completed
 Have Family Doctor                    Child Has Physical / WCC                 Physical Follow-Up Completed
 Have Family Dentist                   Child Has Dental Exam                    Dental Follow-Up Completed
                                      Child Development Information / Goals
 Ideas To Develop Early Reading Skills                              Setting Limits / Discipline
 Sharing Info=Childcare & EHS/HS                                    Improving My Child’s Self-Esteem
 (Circle) Anger, Bedtime/Daily Routines, Depression, Being Disrespectful, Fears, Lying, Sibling Relations, Self-Help
   Skills, Thumb Sucking, Violence
Identified Strengths:
 Attends Parent Group Trainings        Do In-Kind Activities                    Enrolled in HS/EHS Before
 Participates in Home Visits           Participates in P/T Conf                 Attends IEP/IFSP Meetings
 Has Attended Parenting Classes        Use Consistent Routines                  Read Parent/Child Magazines
 Attends Fatherhood Activities         Working Toward/Has CDA                   Attend Child Develop. Class
                            Personal & Family Development Information / Goals
 Finding A Job / Employment Opportunities                           Unemployment / SSI / SSDI Information
 Family Activities To Help My Child Learn                           Budgeting / Credit Counseling
 Adult Ed: High School, ELL, GED, College                           Counseling / Having Someone To Talk To
 Determining If I’m In A Healthy Relationship                       Strengthening My Relationship / Marriage
 (Circle) Raising My Grandchild, Co-Parenting, Sharing Custody, Father Involvement
Identified Strengths:
 Parent(s) Working                     Attend ELL/GED/High School             Attend College
 Receiving SSI/SSDI                    Good Co-Parenting Relations            Non-Residential Parent Active
 Use Family Budget                     Quality Family Time Together           Strong Support System
 Child In Counseling                   Family Attends Counseling              Attend Marriage Counseling
                                Housing & Transportation Information / Goals
 Assistance Finding Housing                                       Getting A Car Seat
 Help With Utilities / Weatherization                             Help Installing A Car Seat
 Help With Transportation (Child to/from center)                  Help With Transportation (Appointments)
Identified Strengths:
 Receiving LIEAP                     Housing Meets Family Needs       Bussing Provided By HS/EHS
 Able To Pay Own Heating             Receive Subsidized Housing       Family Has Vehicle(s)
 Home Is Winterized                  Children Have Own Bedrooms       Family Has Appropriate Car Seat(s)

Information Provided:                       Date Given    Follow-Up Date    Follow-Up:
1.                                                                          No Further Questions   More Info Requested
2.                                                                          No Further Questions   More Info Requested
3.                                                                          No Further Questions   More Info Requested
4.                                                                          No Further Questions   More Info Requested
5.                                                                          No Further Questions   More Info Requested
6.                                                                          No Further Questions   More Info Requested
7.                                                                          No Further Questions   More Info Requested
8.                                                                          No Further Questions   More Info Requested


P:\Forms\Family Partnership Agreement-EHS                                                   (7/07)                      6
                              Family Partnership Agreement Family Goals
                                                                                      Parent
   Goal:
                                                                                      Initial:

   Date Goal Began:            Planned Completion:             Person(s)
                                On-Going           (Month)   Responsible:Family,   HS/EHS Staff



   Steps/Plan to complete goal:
   1.
   2.
   3.
   4.
   5.


   FOLLOW-UP/PROGRESS TOWARD GOAL COMPLETION MAY ALSO BE LOCATED IN:
         & Family Staffings 
             Child                   Family Contacts  Conf. Reports
                                                      P/T                            
                                                                                      Anecdotal Record/Observations
          IEP/IFSP Info / 10’s    Lesson Plans
                                     HV              
                                                      Attendance Record               Section in Child File
                                                                                      Health
           ESP/DIAL Parent Quest. 
                                     ASQ-SE          
                                                      Other




   Additional Documented Follow-up:




   Date Goal Completed:
 (7/07)                                                                                                               7
(P:\Forms\Family Partnership Agree – EHS)
 (7/07)                                     8
(P:\Forms\Family Partnership Agree – EHS)
                              Family Partnership Agreement Family Goals
                                                                                      Parent
   Goal:
                                                                                      Initial:

   Date Goal Began:            Planned Completion:             Person(s)
                                On-Going           (Month)   Responsible:Family,   HS/EHS Staff



   Steps/Plan to complete goal:
   1.
   2.
   3.
   4.
   5.


   FOLLOW-UP/PROGRESS TOWARD GOAL COMPLETION MAY ALSO BE LOCATED IN:
         & Family Staffings 
             Child                   Family Contacts  Conf. Reports
                                                      P/T                            
                                                                                      Anecdotal Record/Observations
          IEP/IFSP Info / 10’s    Lesson Plans
                                     HV              
                                                      Attendance Record               Section in Child File
                                                                                      Health
           ESP/DIAL Parent Quest. 
                                     ASQ-SE          
                                                      Other




   Additional Documented Follow-up:




   Date Goal Completed:
 (7/07)                                                                                                               9
(P:\Forms\Family Partnership Agree – EHS)
 (7/07)                                     10
(P:\Forms\Family Partnership Agree – EHS)
                              Family Partnership Agreement Family Goals
                                                                             Parent
   Goal:
                                                                             Initial:

   Date Goal Began:            Planned Completion:    Person(s)
                                On-Going  (Month)   Responsible:   Family, HS/EHS Staff



   Steps/Plan to complete goal:
   1.
   2.
   3.
   4.
   5.


   FOLLOW-UP/PROGRESS TOWARD GOAL COMPLETION MAY ALSO BE LOCATED IN:
         & Family Staffings 
             Child                   Family Contacts  Conf. Reports
                                                      P/T                   
                                                                             Anecdotal Record/Observations
          IEP/IFSP Info / 10’s    Lesson Plans
                                     HV              
                                                      Attendance Record      Section in Child File
                                                                             Health
           ESP/DIAL Parent Quest. 
                                     ASQ-SE          
                                                      Other




   Additional Documented Follow-up:




   Date Goal Completed:
 (7/07)                                                                                                      11
(P:\Forms\Family Partnership Agree – EHS)
 (7/07)                                     12
(P:\Forms\Family Partnership Agree – EHS)
                              Family Partnership Agreement Family Goals
                                                                                       Parent
   Goal:
                                                                                       Initial:

   Date Goal Began:            Planned Completion:             Person(s)
                                On-Going           (Month)   Responsible: Family,   HS/EHS Staff



   Steps/Plan to complete goal:
   1.
   2.
   3.
   4.
   5.


   FOLLOW-UP/PROGRESS TOWARD GOAL COMPLETION MAY ALSO BE LOCATED IN:
         & Family Staffings 
             Child                   Family Contacts  Conf. Reports
                                                      P/T                             
                                                                                       Anecdotal Record/Observations
          IEP/IFSP Info / 10’s    Lesson Plans
                                     HV              
                                                      Attendance Record                Section in Child File
                                                                                       Health
           ESP/DIAL Parent Quest. 
                                     ASQ-SE          
                                                      Other




   Additional Documented Follow-up:




   Date Goal Completed:
 (7/07)                                                                                                                13
(P:\Forms\Family Partnership Agree – EHS)
 (7/07)                                     14
(P:\Forms\Family Partnership Agree – EHS)
                              Family Partnership Agreement Family Goals
                                                                                       Parent
   Goal:
                                                                                       Initial:

   Date Goal Began:            Planned Completion:             Person(s)
                                On-Going           (Month)   Responsible: Family,   HS/EHS Staff



   Steps/Plan to complete goal:
   1.
   2.
   3.
   4.
   5.


   FOLLOW-UP/PROGRESS TOWARD GOAL COMPLETION MAY ALSO BE LOCATED IN:
         & Family Staffings 
             Child                   Family Contacts  Conf. Reports
                                                      P/T                             
                                                                                       Anecdotal Record/Observations
          IEP/IFSP Info / 10’s    Lesson Plans
                                     HV              
                                                      Attendance Record                Section in Child File
                                                                                       Health
           ESP/DIAL Parent Quest. 
                                     ASQ-SE          
                                                      Other




   Additional Documented Follow-up:




   Date Goal Completed:
 (7/07)                                                                                                                15
(P:\Forms\Family Partnership Agree – EHS)
 (7/07)                                     16
(P:\Forms\Family Partnership Agree – EHS)
                              Family Partnership Agreement Family Goals
                                                                                      Parent
   Goal:
                                                                                      Initial:

   Date Goal Began:            Planned Completion:             Person(s)
                                On-Going           (Month)   Responsible:Family,   HS/EHS Staff



   Steps/Plan to complete goal:
   1.
   2.
   3.
   4.
   5.


   FOLLOW-UP/PROGRESS TOWARD GOAL COMPLETION MAY ALSO BE LOCATED IN:
         & Family Staffings 
             Child                   Family Contacts  Conf. Reports
                                                      P/T                            
                                                                                      Anecdotal Record/Observations
          IEP/IFSP Info / 10’s    Lesson Plans
                                     HV              
                                                      Attendance Record               Section in Child File
                                                                                      Health
           ESP/DIAL Parent Quest. 
                                     ASQ-SE          
                                                      Other




   Additional Documented Follow-up:




   Date Goal Completed:
 (7/07)                                                                                                               17
(P:\Forms\Family Partnership Agree – EHS)
 (7/07)                                     18
(P:\Forms\Family Partnership Agree – EHS)
                              Family Partnership Agreement Family Goals
                                                                                       Parent
   Goal:
                                                                                       Initial:

   Date Goal Began:            Planned Completion:             Person(s)
                                On-Going           (Month)   Responsible: Family,   HS/EHS Staff



   Steps/Plan to complete goal:
   1.
   2.
   3.
   4.
   5.


   FOLLOW-UP/PROGRESS TOWARD GOAL COMPLETION MAY ALSO BE LOCATED IN:
         & Family Staffings 
             Child                   Family Contacts  Conf. Reports
                                                      P/T                             
                                                                                       Anecdotal Record/Observations
          IEP/IFSP Info / 10’s    Lesson Plans
                                     HV              
                                                      Attendance Record                Section in Child File
                                                                                       Health
           ESP/DIAL Parent Quest. 
                                     ASQ-SE          
                                                      Other




   Additional Documented Follow-up:




   Date Goal Completed:
 (7/07)                                                                                                                19
(P:\Forms\Family Partnership Agree – EHS)
 (7/07)                                     20
(P:\Forms\Family Partnership Agree – EHS)
                              Family Partnership Agreement Family Goals
                                                                                       Parent
   Goal:
                                                                                       Initial:

   Date Goal Began:            Planned Completion:             Person(s)
                                On-Going           (Month)   Responsible: Family,   HS/EHS Staff



   Steps/Plan to complete goal:
   1.
   2.
   3.
   4.
   5.


   FOLLOW-UP/PROGRESS TOWARD GOAL COMPLETION MAY ALSO BE LOCATED IN:
         & Family Staffings 
             Child                   Family Contacts  Conf. Reports
                                                      P/T                             
                                                                                       Anecdotal Record/Observations
          IEP/IFSP Info / 10’s    Lesson Plans
                                     HV              
                                                      Attendance Record                Section in Child File
                                                                                       Health
           ESP/DIAL Parent Quest. 
                                     ASQ-SE          
                                                      Other




   Additional Documented Follow-up:




   Date Goal Completed:
 (7/07)                                                                                                                21
(P:\Forms\Family Partnership Agree – EHS)
 (7/07)                                     22
(P:\Forms\Family Partnership Agree – EHS)
                              Family Partnership Agreement Family Goals
                                                                                       Parent
   Goal:
                                                                                       Initial:

   Date Goal Began:            Planned Completion:             Person(s)
                                On-Going           (Month)   Responsible: Family,   HS/EHS Staff



   Steps/Plan to complete goal:
   1.
   2.
   3.
   4.
   5.


   FOLLOW-UP/PROGRESS TOWARD GOAL COMPLETION MAY ALSO BE LOCATED IN:
         & Family Staffings 
             Child                   Family Contacts  Conf. Reports
                                                      P/T                             
                                                                                       Anecdotal Record/Observations
          IEP/IFSP Info / 10’s    Lesson Plans
                                     HV              
                                                      Attendance Record                Section in Child File
                                                                                       Health
           ESP/DIAL Parent Quest. 
                                     ASQ-SE          
                                                      Other




   Additional Documented Follow-up:




   Date Goal Completed:
 (7/07)                                                                                                                23
(P:\Forms\Family Partnership Agree – EHS)
 (7/07)                                     24
(P:\Forms\Family Partnership Agree – EHS)
                              Family Partnership Agreement Family Goals
                                                                                       Parent
   Goal:
                                                                                       Initial:

   Date Goal Began:            Planned Completion:             Person(s)
                                On-Going           (Month)   Responsible: Family,   HS/EHS Staff



   Steps/Plan to complete goal:
   1.
   2.
   3.
   4.
   5.


   FOLLOW-UP/PROGRESS TOWARD GOAL COMPLETION MAY ALSO BE LOCATED IN:
         & Family Staffings 
             Child                   Family Contacts  Conf. Reports
                                                      P/T                             
                                                                                       Anecdotal Record/Observations
          IEP/IFSP Info / 10’s    Lesson Plans
                                     HV              
                                                      Attendance Record                Section in Child File
                                                                                       Health
           ESP/DIAL Parent Quest. 
                                     ASQ-SE          
                                                      Other




   Additional Documented Follow-up:




   Date Goal Completed:
 (7/07)                                                                                                                25
(P:\Forms\Family Partnership Agree – EHS)
 (7/07)                                     26
(P:\Forms\Family Partnership Agree – EHS)

								
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