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Scheme Code: SUH |
Volunteer Name: |
Month/Year: |
HS Family No: |
Vol No: |
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Planned visit date |
Visit took place? Y/N |
A Reason visit did not take place* Code 1-6 |
B Who did you see at home when you visited? |
Visit start time |
Visit end times |
C Activities*
Code 1 - 5 |
D Services* |
Telephone/ Text contact instead of visit? Yes/No |
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D Use code to indicate service* |
E Role with service Code 1 -6 |
Date of family using service |
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A |
Reason visit did not take place (select one only) |
B |
Who did you see at home (incl all there) |
E |
Role related to service use –see D (select all appropriate) |
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1 |
Parent cancelled |
M |
Mum |
1 |
Signposting the service, gave address, contact details etc |
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2 |
Parent rearranged |
D |
Dad |
2 |
Transport – provided transport to the appointment |
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3 |
Volunteer cancelled |
C1 |
Oldest child |
3 |
Accompanying – went to the appointment with the family |
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4 |
Volunteer rearranged |
C2 |
Second child (continue as nec, C3, C4 etc) |
4 |
Discussed information about the service prior to or following use |
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5 |
Parent not at home |
O |
Other (specify eg neighbour, relative etc) |
5 |
Looked after children while parents used service |
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6 |
Other (specify) |
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6 |
Other (specify) |
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C |
ACTIVITIES (select all appropriate) |
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1 |
Practical support (eg budgeting, telephone calls, cooking, shopping, improving hygiene, help with routine/behaviour, writing letters, respite, took family out) |
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2 |
Activities with children (eg playing with children, reading, listening to children, fun outdoor activity; help with routine/activity) |
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3 |
Emotional support (listening, empathising) |
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4 |
Support to use other service (eg signposting accompanying, discussing prior to/after appointment) |
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5 |
Other (specify) |
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D |
SERVICES |
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1 |
Family G.P. |
10 |
Housing advice/support |
19 |
Religious organisations |
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2 |
Health Visitor |
11 |
Benefits Dept |
20 |
Free eye sight tests |
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3 |
Social worker |
12 |
Speech & Language |
21 |
Attended appointments |
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4 |
Mother & Baby clinic |
13 |
CPN/Mental Health |
22 |
Dental check |
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5 |
Children’s Centre (Sure Start) |
14 |
CAMHS |
23 |
Up to date vaccination |
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6 |
Job Centre Plus |
15 |
Adult education |
24 |
Other voluntary service |
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7 |
CAB |
16 |
Received books free from Bookstart |
25 |
Other statutory service |
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8 |
Debt counselling |
17 |
Family joined local library |
26 |
Internet access |
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9 |
Turn2Us online &/or helpline services |
18 |
Toddler group/Nursery/School |
27 |
Parenting programme |
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Volunteer structured diary continued
Has the family had a recent life event, during support or within 1 year before the start of support? If yes, please state when and describe briefly.
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Life Event |
Date |
Describe |
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1. Recent bereavement |
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2. Change in employment status |
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3. Reduction in income(e.g. benefits, tax credits, salary) |
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4. Change in relationship, ie separation, new partner/marriage |
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5. Serious Illness – parent/child? |
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6. New birth |
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7. A&E visit – adult/children? |
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8. Becoming a carer |
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9. Change in housing |
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10. Change in Immigration status |
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11. Other (specify) |
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Other volunteer comments: Please add any additional information:
(Include here any supportive telephone call or text (1); emergency, eg hosp (2); outing (3); celebration (4); other (5)
This form must be completed after each visit or contact with the family. It should be returned to the Home-Start office each month together with your expense form. It is important that the scheme has a record of contact with the family, so if you are unable to return the form to the office, then you should give the information to your organiser/co-ordinator over the phone.
Please use the coding system to complete each column with an *. Note there may be more than one activity or service for each visit. You may also play more than one role in supporting families with each service; please ensure the roles you play are noted alongside each service. For example, you may accompany your family on an appointment (3) then you may discuss the information from the appointment with them afterwards (4). Or you may signpost them to a service (1) and discuss how they could best use the service prior to an appointment (4).
If you have any question please call the office.