ATTCHMNT B PRGM IMPLNTN INSTRUMNTS TOOLS.PDF

ATTACHMENT B -PROGRAM IMPLEMENTATION INSTRUMENTS AND TOOLS
FTF-RC011-19-0612-00 Page 90 of 227

Adverse Childhood Experiences Score
Client ID: Client Name: DOB:
Date: Nurse Home Visitor ID: Nurse Home Visitor Name:
While you were growing up, during the first 18 years of your life:
1. Did a parent or other adult in your household
often or very often... 5. Did you often or very often feel that...
Swear at you, insult you, put you down, You didn't have enough to eat, had to
or humiliate you? wear dirty clothes, and had no one to
or protect you?
Act in a way that made you afraid that or
you might be physically hurt? Your parents were too drunk or high to
EYes LNo take care of you or to take you to a
2. Did a parent or other adult in your household doctor if you needed it?
often or very often... 0 Yes aro
Push, grab, slap, or throw something at 6. Were your parents ever separated or
you? divorced?
or El Yes r-No
Ever hit you so hard you had marks or
were injured? 7. Was your mother or stepmother:
E Yes FIN o Often or very often pushed, grabbed,
slapped, or had something thrown at
3. Did an adult or person at least 5 years older her?
than you ever... or
• Touch or fondle you or have you touch Sometimes, often, or very often
their body in a sexual way? kicked, bitten, hit with a fist, or hit with
or something hard?
Attempt or actually have oral, anal, or or
vaginal intercourse with you? Ever repeatedly hit at least a few times
El Yes Eke or threatened with a gun or knife?
4. Did you often or very often feel that... El Yes L_No
No one in your family loved you or 8. Did you live with anyone who was a problem
thought you were important or special? drinker or alcoholic or who ever used street
or drugs?
Your family didn't look out for each other, ▪ Yes LINo
feel close to each other, or support each
other? 9, Was a household member depressed or
Yes EiVo mentally ill, or did a household member
attempt suicide?
▪ Yes ENo
10. Did a household member go to prison?
1:1 Yes EN o
Updated October 2016

6 ASQ:SE
Month
Ages & Stages
Questionnaire Questionnaires
3 months 0 days through 8 months 30 days
Date A5Q:5E-2 completed:
Baby's information
Baby's first name: aaby s middle InitiaL Baby's last name:
Baby's date of birth: If baby was born 3 or more weeks premature,
please enter the number of weeks;
Baby's gender; Male 0 emaie
Person filling out questionnaire
First name: Middle initial: Last name;
Street address:
City: State/
province: ZIP/postal code:
Home Other
Country: telephone telephone
number: number;
E-mail address;
Relationship to baby: Parent 0 Guarthari 0 Teachee
0 Otter:
0 Child care
other relative parent provider
People assisting in questionnaire completion:
Program information (For program use only)
Baby's ID 4; Age at administration
in months and days:
Program ID 4; If premature, adjusted age
in months and days:
Program name:
P201060000 Ages et Stages QuestIonnaires0:Social-Emodona/ ., Second Ecfition (ASO:SE-2M Squires, Bricker; & Twombly.
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6
Month Questionnaire 3 months 0 days thrnugl 3 months 30 days
Questions box Ef that about best behaviors babies may have are listed on the following pages. Please read each question carefully and check the
describes your baby's behavior. Also, check the circle el if the behavior is a concern.
Important Points to Remember:
ra Answer questions based on what you know about your Please return this questionnaire by:
baby's behavior,
01 Answer questions based on your baby's usua1 behavior, If you have any questions or concerns about your baby
not behavior when your baby is sick, very tired, or hungry, or about this questionnaire, contact:
01• Caregivers who know the baby well and spend more than Thank you and please look forward to filling out another
15-20 hours per week with the baby should complete ASQ:SE -2. ASO:SE-2 months.
OFTEN OR SOME- ; RARELY OR
AUNAYS TIMES NEVER
1. When upset, can your baby calm down within a half hour?
2. Does your baby smile at you and other
family members?
3. Does your baby like to be picked up and held?
4. Does your baby stiffen and arch her back when picked up?
5. When you talk to your baby, does he look at you and seem to
listen?
6. Does your baby let you know when she is hungry or sick?
7. Does your baby seem to enjoy watching or listening to people?
For example, does he turn his head to look at someone talking?
P201060100 Ages & Stages Quest;onnairase; tI 2015 Paul Socjaf-Emotional, H. Brookes Second EcMinn (ASO;5E-2" 0.}, Squires, Bricker, 84 Twombly,
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6 Month Questionnaire Chcck frpa box that best describes your behavia -,
Aiso, check the circie e5 f the behavior I5 a concern.
8. Is your baby able to calm herself down (for
example, by sucking her hand or pacifier)?
9. Does your baby cry for long periods of time?
10. Is your baby's body relaxed?
11. Does your baby have trouble sucking from a breast or bottle?
12. Does it take longer than 30 minutes to feed your baby?
13. Do you and your baby enjoy feeding times together?
14. Does your baby have any eating problems, such as gagging,
vomiting, or ? (Please describe.)
15. During the day, does your baby stay awake for an hour or longer
at one time?
16. Does your baby have trouble falling asleep at naptime or at night?
P201060200 Ages & Stages Ouestionnairese: 0 201S PaLi 5ocral-Ernotio4, H. Brookes Pubfrshing Second Edition (A.SQ:SE-2",), Squires, Bricker, & rwomby
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6 Month Questionnaire Rt. AS :SE Check the box 21- that best descrlbes your child's behavior.
• Also, check the cirde g if the behavior is a concern.
OFTEN OR SOME RARELY OR CHECK THIS IS IF A
ALWAYS rIMES NEVER CONCERN
17. Does your baby sleep at least 10 hours
in a 24-hour period?
18. Does your baby get constipated or have diarrhea?
0
19. Does your baby make sounds and look at you while playing
with you?
20. Does your baby make sounds or use gestures to get your
attention?
21. When you smile at your baby, does he smile back at you?
22. When you talk or make sounds to your baby, does she make
sounds back?
23. Has anyone shared concerns about your baby's behaviors? ff
"sometimes" or "often or always," please explain:
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6 Month Questionnaire
OVERALL Use the spice beiovv for additional comments.
24. Do you have concerns about your baby's eating or sleeping behaviors? If yes, please explain:
NO
25. Does anything about your baby worry you? If yes, please explain:
0 YES NO
26. What do you enjoy about your baby?
P201060400 Ages & Stages Questiormairest: Sociai -ErnadonA second Ethtion (ASO:SE -2",), SquIres, Bricker, & Twombly,
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Month Information Summary 3 months 0 days through 8 months 20 days As_g_K-j\'
Baby's name:
Date ASQ:SE-2 completed:
Baby's ID 4:
Baby's date of birth:
Person who completed ASO:SE-2:
Baby's age/adjusted age in months and days:
Administering program/provider:
Baby's gender: 0 Male (3 Female
1. ASO:SE-2 SCORING CHART:
• Score items (Z 0, V 5, X 10, Concern e 5), Cutoff Total
• Transfer the page totals and add them for the total score, score
• Record the baby's total score next to the cutoff.
45
Total score
2. ASQ:5E-2 SCORE INTERPRETATION: Review the approximate location of the baby's total score on the scoring
check off the area for the score results below. graphic. Then,
no or low risk 11111111.1.1.1.
30 monitor 45 refer .554-
The baby's total score is in the =I area, It is below the cutoff. Social-emotional 90%i/e)
The baby's total score is in the I= area. It is close to the cutoff, Review development appears to be on schedule,
behaviors of concern and monitor,
The baby's total score is in the MI area It is above the cutoff. Further assessment with a professional
may be needed.
3. OVERALL RESPONSES AND CONCERNS: Record responses and transfer parent/caregiver
follow-up. comments, YES responses require
1-23. Any Concerns marked on scored items? YES no Comments:
24. Eating/sleeping concerns? YES no Comments:
25. Other worries? YES no Comments:
4. FOLLOW-UP REFERRAL CONSIDERATIONS: Mark all as Yes, No, or Unsure (y N, U), See pages 98-103 in the ASCISE-2
Setting/time factors (e.g., Is the baby's behavior the same at home as at school?) User's Guide.
Developmental factors (e.g. Is the baby's behavior related to a developmental stage or delay?)
Health factors (e.g., Is the baby's behavior related to health or biological factors?)
Family/cultural factors (e.g., Is the baby's behavior acceptable given the baby's cultural or family context? Have
any stressful events in the baby's life recently?) there been
Parent concerns (e.g., Did the parent/caregiver express any concerns about the baby's behavior?)
S. FOLLOW-UP ACTION: Check all that apply.
Provide activities and rescreen in months.
Share results with primary health care provider.
Provide parent education materials.
Provide information about available parenting classes or support groups.
Have another caregiver complete ASQ:SE-2. List caregiver here (e.g., grandparent, teacher):
Administer developmental screening (e.g., ASC1-3).
Refer to early intervention/early childhood special education.
Refer for social-emotional, behavioral, or mental health evaluation.
Other:
P201060500 Ages & Stager Questionnaires% Social-Emotiotrai, Second Edition (ASQ:SE-2" 1), SquIres, Brickei, fr Twombly.
© 2015 Paul H. Brookes Publishing Co., Inc. All rights reserved.

Ages & Stages
Questionnaires®
t
3 months 0 days through 4 months 30 days
4
Month Questionnaire
nease provide the -following irlformat Iora. Uso black of blue ink only and print
legibly when comOedng this form,
Date ASQ completed:
Baby's information
Baby's first name: Miciclfe
initial: Baby 's last name:
IF baby was born 3 Baby's gender
or reore weeks
Baby's date of bath: premotore;y, # 0 Fernoie
weeks premature:
Person filling out questionnaire
First name:
Lost narne:
Relationship to baby:
Street addres: 0 Parent (1) Guardian Tea Teacher (Th Child rare
ornyks:ei
Grandparent Foster
or other parent Other:
relative
city: State,/ 71Pi
Province:
Postai coder
Home Other
Country.: tofephone telephone
number: number:
&mail address:
Names of people assisting iii questionnaire eornple iron;
Program Information
Baby ID #:
Age at administration in mouths and dayv
Program ID 0:
It premature, adjested age in irunths and days:
Program ndrile;
P101040100 Ages & Stages uues(ionnajrasQ, Third Edition (AS0-3TI'), Squires & Bricker
2009 Paul H. Brookes Publishing Co. All rights reserved.

4 Month Questionnaire 3 months 0 days
throu9h 4 months 30 days
On the following pages are questions about activities babies may do. Your baby may have already
described here, and there may be some your baby has not begun doing yet. For done some of the activities
cates whether your baby is doing the activity regularly, each item, please fill in the circle that indi-
sometimes, or not yet.
Important Points to Remember;
Notes:
4 Try each activity with your baby before marking a response.
▪ Make completing this questionnaire a game that is fun for
you and your baby.
• Make sure your baby is rested and fed,
• Please return this questionnaire by
COMMUNICATION
YES SOMET1r.dES Naf YET
1. Does your baby chuckle softly?
O
2. After you have been out of sight, does your baby smile or get excited
when he sees you? 0
3. Does your baby stop crying when she hears a voice other than yours?
4. Does your baby make high-pitched squeals?
0
5. Does your baby laugh?
0
6. Dees your baby make sounds when looking at toys or people?
C.OM M ON ICATION TOTAL
GROSS MOTOR
YES SONIFTIN4Es NOT YET
1, While your baby is on his back, does he move his head from side to 0
side?
2, After holding her head up while on her tummy, does your baby lay her
head back down on the floor, rather than let it drop or fall forward? 0
3. When your baby is on his tummy, does he hold his
head up so that his chin is about 3 inches from the 0 0 0
floor for at least 15 seconds?
4. When your baby is on her tummy, does she hold her
head straight up, looking around? (She can rest on her 0
arms while doing this.)
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4ASQ3
4 Month Questionnaire pev J
GROSS MOTOR (coitrinrre Cii)
YES St rirrI ET IM NOT YET
5, When you hold him in a sitting position, does your baby hold his head
steady? 0
6. While your baby is on her back, does your
baby bring her hands together over her chest,
touching her fingers?
FINE MOTOR
YES Olvili= ritt NO-1 YET
1. Does your baby hold his hands open or partly open (rather
than in fists, as they were when he was a newborn)?
2. When you put a toy in her hand, does your baby wave it about, at least
briefly?
3. Does your baby grab or scratch at his clothes?
0
4. When you put a toy in her hand, does your baby hold onto it for about
1 minute while looking at it waving it about, or trying to chew it? 0 0
5. Does your baby grab or scratch his fingers on a surface in front of him, r-,
either while being held in a sitting position or when he is on his tummy?
6. When you hold your baby in a sitting position, does she reach for a toy
on a table close by, even though her hand may not touch it? 0 0
PROBLEM SOLVING
YE. 5 SCMF.TlWES NOT VET
1. When you move a toy slowly from side to side in front of your baby's
face (about 10 inches away), does your baby follow the toy with his 0
eyes, sometimes turning his head?
2. When you move a small toy up and down slowly in front of your baby's 0
face (about 10 inches away), does your baby follow the toy with her
eyes?
3. When you bold your baby in a sitting position, does he lock at a toy
(about the size of a cup or rattle) that you place on the table or floor in
front of him?
4. When you put a toy in her hand, doer your baby look at it?
0
5. When you put a toy in his hand, does your baby put the toy in his
mouth?
E I 01040300 SNiOes Quesrroonairesi9, Third Edition ;',480-3''''), Squires & Bricker
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AASQ3 4 Month Questionnaire pg 4o , 5
PROBLEM SOLVING i'Lcori/inut-r0 SOMETIMP3 NOT YE]
6. When you dangle a toy above your baby while she 0
is lying on her back, does your baby wave her arms
toward the toy?
PROBLEM 'SOLVING TO1AL
PERSONAL-SOCIAL
NOT YET
1. Does your baby watch his hands? 0
2, When your baby has her hands together, does she play with her 0 0
fingers?
3, When your baby sees the breast or bottle, does he seem to know he is
about to be fed?
4. Does your baby help hold the bottle with both hands at once, or when 0 rTh
nursing, does she hold the breast with her free hand?
5. Before you smile or talk to your baby, does he smile when ho sees you 0 a 0
nearby?
6. When in front of a large mirror, does your baby
smile or coo at herself?
I )1\JALSOCJAI TOTAL
OVERALL
Parents and providers may use the space below for additional comments.
1. Does your baby use both hands and both legs equally well? if no, 0 YES 0 NO
explain:
2. When you help your baby stand, are his feet flat on the surface most 0 0 NO
of the time? If no, explain:
A905 13c Stdges Quost/orinaireslP, Thiid Edition ;IASQ -3"', $ciu6 et;& Bricker
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.4ASQ3i 4 Month Questionnaire page 5 of 5
OVERALL conti PUP d)
3. Do you have concerns that your baby is too quiet or does not make sounds like C__,) YES
other babies? If yes, explain:
4. Does either parent have a family history of childhood deafness or hearing IS) YI •
impairment? if yes, explain:
5. Do you have concerns about your baby's vision? If yes, explain: 0 NO
6. Has your baby had any medical problems in the last several months? 0 YE.s 0 NO
If yes, explain;
7. Do you have any concerns about your baby's behavior? If yes, explain: C 0 No
8. Does anything about your baby worry you? If yes, explain: 0 'YES
El 01040500 Ages & Stage::: Ouestioriroiresre, Third Fclition (ASC-L3 -'4,1, St.tu IT 05 8; Bricker
Q. 2009 Ntli H. Brookes FulAshing Co. At rigiTcs reserved.

4 Month ASQ-3 Information Summary 3 months 0 daysthrough
4 months 30 days
Baby's name: _
Date ASO completed:
Baby's ID tt:
Date of birth: _
Administering program/provider: Was age adusred for prematurity
when selecting questionnaire? 0 Ye
1. SCORE AND TRANSFER TOTALS TO CHART BELOW: See 450-3 tiger's Guide
responses are missing. Score each item (YES = 10, SOMETIMES — 5, NOT for details, including how to adjustiscores if item
In the chart below, transfer the total scores, and fill in the circles YET 0). Add item scores, and record each area total.
corresponding with the total scores.
Totaf
Area IcLJto,.ffi score . 0 5 10 15 20 25 30 35 40 45
comrnicatior. 34.60 • • • • a • • 50 55 60
Gl.wz Motor 38,41 • •00 00
Fine Motor 29.62 • • • • • 0 0
Problem Solving 34,98 • • • • a • • 0 0 00
Pei sonaf.social • • • • • 0 0 0
4 -1
0
2. TRANSFER OVERALL RESPONSES: Bolded uppercase responses require
follow-up. See 4S0-3 User's Guide, Chapter 6.
1. Uses both hands and both legs equally well? Yes NO 5. Concerns
Comments: about vision? YES No
Comments:
2. Feet are flat on the surface most of the time? Yes NO 6. Any medical
Comments: problems? YES No
Comments:
3. Concerns about not making sounds? YES No 7. Concerns about
Comments: behavior? YES No
Comments:
4. Family history of hearing impairment? YES No 8. Other
Comments: concerns? YES No
Comments:
3. ASO SCORE INTERPRETATION AND RECOMMENDATION FOR FOLLOW-UP:
responses, and other considerations, such as opportunities to practice You must consider total area scotes, overall
skills, to determine appropriate follow-up.
If the baby's total score is in the El area, it is above the cutoff, and the baby's development
If the baby's total score is in the area, it is close to the cutoff. Provide appears to be on schedule.
If the baby's total score is in the 1•1111 area, it is below the cutoff, Further learning activities and monitor.
assessment with a professional may be needed.
4. FOLLOW-UP ACTION TAKEN: Check all that apply.
5. OPTIONAL: Transfer item responses
Provide activities and rescreen in months. YES, S = SOMETIMES, N NOT YET,
Share results with primary health care provider. X = response missing).
Refer for (circle all that apply) hearing, vision, and/or behavioral screening.
Refer to primary health care provider or other community agency (specify Communication
reason): (v:eoss Motor
Refer to early intervention/early childhood special educat i on. Flne Moto
No further action taken at this time Prnbiein Solving
Other (specify): Pelsonai-So6rit
,---..
P101040600 Agos & Stagr,is QuostiorniairosAi r third Edition JASQ-3!". 1), Squire:. & Brkkei -
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Partnership
Client Dismissal/Transfer NAM, 1.1".71,0 lbero.6rerrd.
Client ID Client Name DOB
Date Nurse Home Nurse Home
Visitor TD Visitor Name
Section I — Discharge Date/Reason — This section is to be entered into the Dismiss Client from
Program screen in ETO.
I. •Date the client was discharged from the program
2. *Please check the primary reason the client is leaving the program (check only one):
ri Child no longer in family's custody (parental rights terminated). Please also complete
section II
H Child reached second birthday
Client incarcerated Please also complete section II
Client is receiving services from another program
Client refused NFP continuation following report to Child Welfare Services
Client returned to work or school
Client received what she needs from the program
Dissatisfied with program
Excessive missed appointments/attempted visits
Infant death Please also complete section II
Maternal death Please also complete section II
Miscarried/fetal death Please also complete section II
Moved out of service area If client is transferring please also complete section III
Nurse resigned and no room in remaining nurses caseloads
Pressure from family
Refused new nurse
• Safety of the nurse
El Unable to accommodate requested schedule
D Unable to contact
• Unable to locate
▪ Unable to serve client due to language
© Copyright 2015 Nurse-Family Partnership. All rights reserved. Page 1 of 3
Ret,iserl November 2015

1\liff,;(2 Farnily
Parinership
Client Dismissal/Transfer
Section II — Supplemental Discharge Information — This section is to be entered into the
Supplemental Discharge Information Assessment in ETO.
Child no longer in family's custody (parental rights terminated)
Date child no longer in family's custody:
E Voluntary
Involuntary
Client incarcerated
Date of client's incarceration:
Infant death
Date of infant's death:
Primary cause of infant's death:
n Disease
Illness
pi Congenital malformation
pi Accidental
Infanticide
I I Unknown
Maternal death
Date of client's death:
Primary cause of client's death:
n Disease
pi Illness
ri Accidental
pi Suicide
n Homicide
ri Unknown
Miscarried/fetal death
Date of miscarriage/fetal death:
C Copyright 2015 Nurse-Family Partnership. All rights reserved. Page 2 of 3
Rguised Nopember 2015

1\Tuise-Fai1ily
Partnership
Client Dismissal/Transfer
Section III — Client Transfer Reason — This section to be entered during the Client Transfer
Process in ETO (See guidance on NFP Community > Quality > Efforts to Outcomes)
Moved out of Service Area
7 Caseload (full and/or Balance)
7 Client requested change
7 Funding Source Change
EI Moved out of service area/zip code
E Nurse resigned
E Nurse returned from leave
El Nurse transferring teams
El Nurse went on leave
E] Unable to accommodate requested schedule
7 Unable to serve client due to language
© Copyright 2015 Nurse-Family Partnership. All rights reserved. Page 3 of 3
Revised November 2015

For notetaking purposes only. Please enter and submit codes and comments electronically online at the following website: http://j.rnpnfdr/RbN.
DANCE Coding Sheet
Video ID Learner's Name Duration
Child's Age Date Coded
Expressed Positive
CA
Affect
Caregiver's Affect
Complements Child's CA
Affect
ieuo1ovu3
Verbal Quality CA
NA I—I
Amen?)
Response to Distress
NA =I
Negative Comments
About the Child to
Others
Positioning
S
ensi Visual Engagement CA
ti
vi
t
y a Pacing CA
nd
R
es Negative Touch
ponsi
vi Non-Intrusiveness CA
t y
Responsiveness
Limit Setting
NAF—I
Completes Interactions
NA I I
Supports
Exploration
Scaffolding CA
leluaLudolanaa
uoRowaid Verbal Connectedness CA
io
41-m019 Praise CA
Negative Verbal
Content II
Observational Parameters: P= when child is present CA= when CG and child are engaged in a caregiving activity D=when distress occurs
C 2016 The Regents of the University of Colorado, a body corporate. All rights reserved.
Dyadic Assessment of Naturalistic Caregiver-child Experiences (DANCE) Coding Sheet— Version 4.0 (08/2016)

Family
Partnership
Demographics: Pregnancy - Intake lidpirtg Fint-lina- Parma Sward
Client ID Client Name DOB
Client SSN
Date Nurse Home Nurse Home
Visitor ID Visitor Name
Section I - Petsonal/Family — This section is to be entered into the View/Edit Client
Demographics screen in ETO.
1. *Client's DOB:
2. *Ethnicity (check one):
D Hispanic or Latina
O Not Hispanic or Latina
O Declined to self-identify
3. *Race (check all that apply)
0American Indian or Alaska Native
n Asian
n Black or African-American
O Native Hawaiian or other Pacific Islander
E White
Cf Declined to self-identify
4. Client's Ancestry (check all that apply):
Afro-Caribbean, excluding Haitian Cf Korean
E Anglo-Dutch Caribbean Cf Laotian
n Arab North African
O Bangladeshi/Bengali Pakistani
D Central American, including Mexican Cf Palestinian
O Chinese Persian
Cf Cuban Polish
O Dominican Puerto Rican
▪ Eritrean Russian
O Filipino Somali
Cf Haitian Sub-Saharan African
E Hmong South American
E Indian (South Asian) Ukrainian
O Israeli Vietnamese
O Other (please specify)
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Revised October 2016

5. + Client's Primary Language (check only one):
E English Korean
El Spanish Mandarin
0 Arabic ri Polish
E Cantonese El Russian
E Creole (Haitian) 0 Tagalog
E French 0 Tribal Languages
E Hindi n Vietnamese
121 Italian n Other (please specify)
O Japanese
6. + Client's Zip Code:
Section II — Other Demographics
1. +Are you participating in this program voluntarily?
LII Yes
▪ No
2. +Marital Status:
E Married (legal or common law)
IEI Single - never married
ri Widowed
I=1 Divorced
O Separated
El Not Married — living with partner
3. •How often do you usually see or talk to the baby's biological father?
ri Not at all
TI Less than once a week
n At least once a week but not daily
n Daily
4. +With whom do you live? (check only one from options I — 5)
O Live with others (check all that apply)
El Client's mother
LI Father of Child (FoC)
• Current husband/partner (not FoC)
O Other family members
LI Infant/child
O Other adults
ri Live alone (or with infant/child)
ri Live in a group home/shelter
E Confined to an institutional facility (residential treatment facility, incarcerated)
E Homeless
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Revised October 2016

1=1 Homeless and sharing housing (skip to 6)
n Homeless and living in emergency or transitional shelter (skip to 6)
• Other (skip to 6)
5. + If you are not homeless, where do you currently live?
• Owns or shares own home, condominium, or apartment
▪ Rents or shares own home or apartment
El Lives in public housing
El Lives with parent or family member
▪ Other
6. •Which members of your family are in the Military — active or reserve? (check all that apply)
El Self (client)
• Client's spouse
1=1 Client's parent(s)
D Father of child (FoC)
D None
Section III — Education and Income
7. •Are you currently enrolled in middle or high school?
E Yes — middle school (66 8 th grades)
• Yes — high school or GED program (includes alternative and technical programs)
• Not enrolled
8. •Have you completed high school or a GED or vocational/certification program?
E Yes - completed high school
I:I Yes - completed GED
ri Yes - completed vocational/certification program
El No. If no, what is the last grade you have completed? grade (skip to 12)
9. + If you have completed high school/GED, are you currently enrolled in any kind of school,
vocational, certification or educational program?
ID Yes
E Full Time — 12 semester hours or equivalent
E Part Time
E 7 — 11 semester hours or equivalent
TI 6 or less semester hours or equivalent
• No (skip to 11)
10. 4 What type of educational program are you currently enrolled in?
E Post-high school vocational/certification/technical training
▪ College
© Copyright 2016 Nurse-Family Partnership. All rights reserved. Page 3 of?
Revised October 2016

11. *Have you completed education other than high school/GED (mark the highest level)?
E Vocational/certification/technical training program (beyond high school)
E Some college (no degree)
0 Associate's degree
n Bachelor's degree
7 Master's degree
P1 Professional degree (for example: LLB, LID, MID, DDS)
O Doctorate degree (for example: PhD, EdD)
fl No
12. •Do you have a plan to enroll in any additional kind of school, vocational, certification or
educational program?
0 Yes
fl No
13. •Are you currently working?
• Yes
E Full-time: 37+ hours per week
n Part-time
P1 20 — 36 hours per week
10 — 19 hours per week
n less than 10 hours per week
111 No
0 Unemployed and seeking employment
7 Not employed (student, homemaker, other)
© Copyright 2016 Nurse-Family Partnership. All rights reserved. Page 4 of 7
Revised October 2016

14. • Which of the following categories best describes your total yearly household income and
types of benefits you receive? Include your income and any other income you may have
received. For the purpose of this question, the household should include only you and your
child. Remember that this information will be kept private and will not affect your access to
services (Use public assistance programs that are for low-income families as a marker if the
client does not know and she qualifies or receives a public assistance program).
Sources of household income include (please check all that apply)
111 Salary/wages from employment
111 Social Security/Disability
▪ TANF
fl Alimony
0 Child Support
111 Rent from tenants
O Cash Assistance from friends/relatives
O Unemployment
0 Other income (please specify)
O Less than or equal to $6,000
111 $6,001 - $9,000
111 $9,001 - $12,000
111 $12,001 - S16,000
111 $16,001 - $20,000
111 $20,001 - $30,000
111 Over $30,000
O Client is dependent on parent/guardian
15. +Do you (client) qualify for TANF, Medicaid, WIC or Foodstamps?
LI Yes
• No
Copyright 2016 Nurse-Family Partnership, All rights reserved. Page 5 of 7
Revised October 2016

16. •In the past 6 months, have you (client) obtained care at the hospital emergency room for any
reason?
El Yes
If yes, what was the purpose of the visit (please check all that apply)?
El Injury — Accidental, how many times? 1 times
El Injury — Intentional self inflicted, how many times? I I times
E Injury — Intentional other inflicted, how many times? times
El Injury — Declined how many times? I times
El Ingestion — Accidental, how many times? I times
E Ingestion — Intentional self inflicted, how many times?
n Ingestion — Intentional other inflicted, how many times?
1=1 Ingestion — Declined, how many times? I times
ri Respiratory infection, how many times? times
n Fever, how many times? F I times
El Other (please specify) how many times? times
E No
CO Copyright 2016 Nurse-Family Partnership. All rights reserved. Page 6 of 7
Revised October 2016

17. *In the past 6 months, have you (client) obtained care at the urgent care center for any reason?
El Yes
If yes, what was the purpose of the visit (please check all that apply)?
Fl Injury — Accidental, how many times? times
D Injury — Intentional self inflicted, how many times? I times
O Injury — Intentional other inflicted, how many times? IL times
El Injury — Declined, how many times? MI times
El Ingestion Accidental, how many times? Ill times
El Ingestion — Intentional self inflicted, how many times? 1 times
• Ingestion — Intentional other inflicted, how many times? I I times
E Ingestion — Declined, how many times? I times
El Respiratory infection, how many times? times
E Fever, how many times? I times
0 Other (please specify) , how many times? 11 times
No
18. *Do you (client) have health insurance coverage?
I=1 Yes
No
If yes, which type of health insurance do you use when you go for medical care? (please
check all that apply)?
▪ Medicaid
n CHIP
▪ Tri-Care
n Private
TI Other (please specify)
© Copyright 2016 Nurse-Family Partnership. All rights reserved. Page 7 of 7
Revised October 2016

sc-Family
Generalized Anxiety Disorder -7 (GAD-7) Partnership
Helping Fint-Trntr Pawn, Sward •
Client ID Client Name I DOB I
Date Nurse Home Nurse Home
Visitor ID Visitor Name
Check one: pi Intake Pregnancy 1---1 Infancy El Infancy Infancy
36 Weeks 1 -8 Weeks 4-6 Months El 12 Months
0 Additional (PRN)
Over the last 2 weeks, how often have you been bothered by the following problems?
1. *Feeling nervous, anxious, or on edge 7. •Feeling afraid as if something awful might
E 0 - Not at all happen
7 1 - Several days El 0 - Not at all
O 2 - More than half the days 0 1 - Several days
7 3 - Nearly every day E 2 - More than half the days
E 3 - Nearly every day
2. • Not being able to stop or control worrying
O 0 - Not at all Add all individual item scores to determine
LI 1 - Several days Total Score:
El 2 - More than half the days
E 3 - Nearly every day
8. If you checked off any problems, how
3. *Worrying too much about different things difficult have these problems made it for
O 0 - Not at all you to do your work, take care of things at
D 1 - Several days home, or get along with other people?
D 2 - More than half the days n Not difficult at all
El 3 - Nearly every day 0 Somewhat difficult
0 Very difficult
4. *Trouble relaxing [I Extremely difficult
O 0 - Not at all
1 - Several days
7 2 - More than half the days
O 3 - Nearly every day Source: Spitzer RL, Kroenke K, Williams JBW, Lowe
B. A brief measure for assessing generalized anxiety
5. *Being so restless that it's hard to sit still permission disorder. Arch required Inern Med. to reproduce, 2006;166:1092-1097. translate, display No or
O 0 - Not at all distribute.
O 1 - Several days
▪ 2 - More than half the days
O 3 - Nearly every day
6. *Becoming easily annoyed or irritable
7 - Not at all
0 1 - Several days
E 2 - More than half the days
D 3 - Nearly every day
Revised June 2015 Page 1 of 2

Nurse-Family
Health Habits Partnership
Helping Fint-nw PafIlt Sward
Client ID Client Name DOB
Date Nurse Home Nurse Home
Visitor Ill Visitor Name
n Pregnancy n Pregnancy Infancy
Check one:
" Intake 36 Weeks 12 Months
I have some questions about smoking cigarettes. Many people smoke at least some time in
their life. Sometimes women who are pregnant will smoke cigarettes before they know they
are pregnant, or they may find it very hard to change a pattern of smoking once they start.
These are questions about regular, nicotine cigarettes only. Joints or Marijuana will be
asked about later.
Questions 1 and 2 are asked only at intake
1. During the 3 months before you became pregnant, how many cigarettes did you usually smoke
in a day?
cigarettes
2. Did you smoke cigarettes at all during your pregnancy, including before you found out you were
pregnant?
El Yes
El No
3. In the last 48 hours, HOW MANY cigarettes have you smoked? By 48 hours, I mean from
(TIME AND DAY OF WEEK) to (TODAY AND TIME).
I cigarettes
4. Do you use other forms of nicotine?
n Yes
If yes, please indicate the types of nicotine you use (please check all that apply).
pi Electronic cigarette (E-cigarette)
ri Patches
ri Dissolvable Tobacco (strips, sticks, orbs and compressed tobacco, lozenges)
ri Cigars
P1 Smokeless tobacco (chewing tobacco and snuff)
D No
Now I am going to ask you some questions about alcohol. Many people drink alcohol at
least some time in their life. Sometimes women who are pregnant will drink before they
know they are pregnant, or they may find it very hard to change a pattern of drinking once
they start. By alcohol, I mean beer, wine, wine coolers, and liquor, such as whiskey, scotch,
gin, rum, or other types of drinks with alcohol in them.
5. OVER THE PAST FOURTEEN DAYS, on how many DIFFERENT DAYS did you use
alcohol?
days (if 0, skip to 7)
C., Copyright 2014 Nurse-Family Partnership. All rights reserved. Page 1 of 2
Revised June 2014

6. OVER THE PAST FOUR I EEN DAYS, when you used alcohol, how many drinks did you
USUALLY have PER DAY?
drinks
Now I am going to ask you a series of questions about many other types of drugs.
Sometimes women who are pregnant will use drugs before they know they are pregnant, or
they may find it very hard to change a pattern of drug use once they start.
These next questions are about marijuana, also called pot or weed.
7. OVER THE PAST FOURI _HEN DAYS, on how many DIFFERENT DAYS did you use
marijuana?
I days (if 0, skip to 9)
S. OVER THE PAST FOURTEEN DAYS, when you used marijuana, how many pipes or
joints did you USUALLY smoke PER DAY?
pipes or joints/day
Now I am going to ask some questions about cocaine. This can be either powdered
cocaine that you sniff OR crack cocaine that you smoke, or cocaine that you inject.
9. OVER THE PAST FOUR _LEEN DAYS, on how many DIFFERENT DAYS did you use
cocaine?
days (if 0, skip to 11)
10. OVER THE PAST FOURTEEN DAYS, when you used cocaine, how many times PER
DAY did you USUALLY use it?
times/day
Now I am going to ask you a few questions about other drugs that people use to get high.
These include AMPHETAMINES, such as speed, uppers, reds, crystal, or ice; LSD, such as
acid, blotter, or trips; other HALLUCINOGENS, such as peyote, ecstasy, mescal, or magic
mushroom; PCP; AMYL NITRATE; or HEROIN, also known as smack, junk, speedball, or
horse; INHALANTS (things that people sniff or huff in order to get high), such as spray
paint, hairspray, gasoline, lighter fluid, glue, or paint thinner.
11. OVER THE PAST FOURTEEN DAYS, on how many DIFFERENT DAYS did you use
these other street drugs?
---I days (if 0 skip 12)
12. OVER THE PAST FOURTEEN DAYS, when you used street drugs, how many times PER
DAY did you USUALLY use them?
times/day
C Copyright 2014 Nurse-Family Partnership. All rights reserved. Page 2 of 2
Repised June 2014

::-Family
Home Visit Encounter Partners ip
INpigg Fini.77nrr PArrno Siderred •
Client ID I Client Name DOB
Date *Time Flom am/pm am m
Total Miles Nurse Home
Visitor ID Nu Visitor se. Home Name
• VISIT: El Completed 0 Attempted 0 Client cancelled visit El Nurse home visitor cancelled visit
• TODAY'S VISIT El Standard Visit Schedule Alternate Visit Schedule
SCHEDULE
*LOCATION OF VISIT: • Client's Home 0 Doctor/Clinic Employment
Family/Friend's Home • School 0 Public/Private Agency
Other
• WHO WAS Client El Current Husband/ • 111 2nd INI -'' 7 PI..) Professional
PRESENT AT THE li Child Partner not FoC Interpreter
VISIT: 0 Client's Mother Other Family Member 0 Other Professional
• Father of Child (FoC) ENFP Supervisor Other
Friend (s) Child Welfare Services
PARTICIPANTS ENGAGED IN VISIT (rate 1= low to 5 = high):
Client Client's Mother Husband/Partner/FOC
Involvement
Conflict lict with material mate al
Understanding of material 1 1
*PERCENT OF TIME SPENT ON EACH PROGRAM AREA: TIME SPENT
My Health (Personal Health - Health Maintenance Practices; Nutrition and Exercise;
Substance Use; Mental Health) %
My Home (Environmental Health - Home; Work; School and Neighborhood) %
My Life (Life Course - Family Planning; Education and Livelihood) %
My Child/ Taking Care of My Child (Maternal Role - Mothering Role; Physical Cate;
Behavioral and Emotional Care of Child) %
My Family & Friends (Personal Network Relationships; Assistance with Childcate) I %
TOTAL 100%
• PERCENT OF TIME SPENT ON PLAN: I %
1. • Do you have any concerns regarding your child's development, behavior or learning?
El Yes 0 No 0 Not Indicated at this visit El N/A (still pregnant)
2. • Since our last visit, have you received any of the recommended prenatal or postpartum visits?
D Yes (if yes, please indicate which of these visits were completed; check all that apply)
[1 6-9 weeks [1 22-25 weeks El 36 weeks [1 40 weeks
El 10-13 weeks [1 26-29 weeks [1 37 weeks D 41 weeks
El 14-17 weeks El 30-32 weeks El 38 weeks [1 1-8 week postpartum
0 18-21 weeks [1 33-35 weeks [1 39 weeks
El No [1 N/A
3. *Since our last visit, has your child had any of the following well-child visits? (check all that apply)
El Yes (if yes, please indicate which of these well child visits were completed; check all that apply)
[1 In the nursery El 3-5 days after birth 1=1 By 1 month old El 2 months old
El 4 months old 0 6 months old 0 9 months old [1 12 months old
[1 15 months old [118 months old [1 24 months old
[1 24 month visit scheduled but not yet completed
0 No D N/A
4. • Since our last visit, have you had continuous health insurance coverage?
D Yes D No
Copyright 2017 Nurse-Family Partnership. All rights reserved. Page 1 of 2
Revised Apil 2017 v2

5. Based on the client's need, what is the next planned visit schedule?
El Standard Visit Schedule 0 Alternate Visit Schedule Increased
1:1 Next visit not scheduled at this time D Alternate Visit Schedule Decreased
ER Visits and Hospitalizations
6. • Since our last visit, have you taken your child to the hospital emergency room/urgent care center for an
injury or because you were concerned your child swallowed something harmful?
El Yes (If yes, please mark the reason and note the date)
NOTE: ER and Urgent Care visits for illness should not be noted
fl Injury Date: (month/day/year) Treatment Needed
El Emergency Room El Urgent Care
Date: / / (month/day/year) 0 Treatment Needed
El Emergency Room D Urgent Care
Date: /__/ (month/day/year) El Treatment Needed
El Emergency Room El Urgent Care
El Ingestion Date: / / (month/day/year) El Treatment Needed
El Emergency Room ID Urgent Care
Date: (month/day/year) El Treatment Needed
0 Emergency Room El Urgent Care
Date: / / (month/day/year) El Treatment Needed
El Emergency Room El Urgent Care
El No El N/A (still pregnant)
7. • Since our last visit, have you taken your child to the hospital emergency room/urgent care center for any
other reason (excluding injury and ingestion)?
LI Yes (If yes, please note the reason and date)
Reason: Date: / / (month/day/year)
El Emergency Room El Urgent Care
Reason: Date: / (month/day/year)
El Emergency Room Urgent Care
Reason: Date: / / (month/day/year)
El Emergency Room 0 Urgent Care
D No 1:1 N/A (still pregnant)
8, • Since our last visit, has your child been admitted to the hospital (that is, had to spend at least one night
there) for an injury or because you were concerned your child swallowed something harmful?
El Yes (If yes, please mask the reason and note the admission date and length of stay for each admission)
NOTE: Hospital stays for illness should not be noted
Injury Date: (month/day/year) i nn i days
Date: (month/day/year) 1 days
Date: (month/day/year) (= days
El Ingestion Date: (month/day/year) days
Date: (month/day/year) F I days
Date: (month/day/year) 1 days
El No El N/A (still pregnant)
Client/Child screened for needed services El Yes No No referral needed
Please complete the Referrals to Services form if any referrals were made at this visit.
Copyright 2017 Nurse-Family Partnership. All rights reserved. Page 2 of 2
Revised April 201 7 ._y2

- .Tse-Family
0
Infant Birth Partnership
ng Firrt..Time Parent, Sward
Infant ID Infant Name *Infant DOB*
Client ID Client Name I DOB
Date Nurse Horne Nurse Home
Visitor ID Visitor Name
*Infant DOB to be entered into the View/Edit Client Demographics screen in ETO.
Multiple birth El
1. Child's Ethnicity (check one):
▪ Hispanic or Latina/Latino
D Not Hispanic or Latina/Latino
2. Child's Race (check all that apply)
fl American Indian or Alaska Native
O Asian
Black or African-American
n Native Hawaiian or other Pacific Islander
O White
3. Gender:
D Male
LI Female
4. Birth weight: grams or lbs. oz.
5. •Gestational age at birth: weeks
6. •Was (child's name) admitted to the NICU because of problems?
O Yes, for how many days prior to being discharged? 1 days
▪ No. If no, did (child's name) have to spend any time in the special care nursery because
of problems?
• Yes, for how many days prior to being discharged? I days
El No
If yes, what was the purpose of the stay (please check all that apply)?
O Low birth weight
El Very low birth weight
O Respiratory distress
D Prematurity
fl Congenital defect
fl Other (please specify)
7. *What was your overall weight gain during pregnancy? I 1lbs.
8. •Has your baby ever received breast milk?
• Yes
E No
Copyiight 2016 Nurse-Vanaily Partnership. All rights reserved. Page 1 of 3
Reriised December 2016

Infant Birth
9. *Ty e of labor
Induced
n Not induced
10. *Type of delivery
El Vaginal
El Caesarean
11. •Did your child receive a newborn screening test in the nursery?
El Yes
▪ No
E Don't know
12. *Did your child receive a hearing screening in the nursery?
E Yes
fl No
El Don't know
Safe Sleep: For questions 13, 14, and 15, select `N/A' if the infant is in the hospital when the
form is completed
13. •How often do you place your infant to sleep on their back?
LI Always
El Sometimes
ID Never
El N/A
14. *How often do you bed-share with your infant?
El Always
El Sometimes
El Never
▪ N/A
15. *How often does your infant sleep with soft bedding?
E Always
E Sometimes
E Never
fl N/A
0 Copyright 2016 Nurse-Family Partnership, All rights reserved. Page 2 of 3
_Revised Deomber 2016

Family
infant Birth artnership
ligoing Parrnf Smerefd
16. +During a typical week, how many days do you (and/or a family member) read, tell stories,
and/or sing songs to your child?
EIO [:1 L12 [:3 4 11 5 6 L7
17. •Does your child have health insurance coverage?
Yes
1-1 No
If yes, which type of health insurance do you use when you take your child for medical care
(please check all that apply)?
0 Medicaid
0 CHIP
El Tr-Care
111 Private
[II Other (please specify)
C Copyright 2016 Nurse-Family Partnership. All rights reserved. Page 3 of 3
Revised December 2016

▪
Lif. -Farnily
Infant Health Care Partnership
Helping Pint:Time Parra &Awed+
Infant ID Infant Name Infant DOB
Infant SSN
Client II) Client Name DOB
Date Nurse Home Nurse Home
Visitor ID Visitor Name
Check one: O Infancy Infancy 1=1 Toddler Toddler
6 Months 12 Months 18 Months 24 Months
1. •During a typical week, how many days do you (and/or a family member) read, tell stories,
and/or sing songs to your child?
• o
1
O 2
• 3
O 4
O 5
• 6
• 7
2. •Where do you usually take (child's name) for routine check-ups (well-child care)?
O Health department
TI Community clinic
F1 Hospital ER
O Hospital clinic
O Hospital Outpatient
O Dr/Nurse Practioner's Office (Private doctor's office)
O FQHC
El Retail store/minute clinic
O Other
10 None
© Copyright 2016 Nurse-Family Partnership. All rights reserved. Page 1 of 5
Revised December 2016

3. •At time of -visit, based on your local immunization schedule (regardless of vaccine brand or
manufacturer) is (child's name) up to date on all vaccinations?
El Yes (If yes, please indicate which of the immunizations were completed)
H Completed all immunizations due for 0-5 months (enter on 6 month form)
ri Completed all immunizations due for 0-11 months (enter on 12 month form)
O Completed all immunizations due for 0-17 months (enter on 18 month form)
O Completed all immunizations due for 0-23 months (enter on 24 month form)
n ▪ Completed all immunizations due for 24 months (enter on 24 month form)
24 month immunizations not completed yet but scheduled with health care provider
(enter on 24 month form)
11 No
El Immunizations were refused
El Unknown
4. •Is the information on child's immunization status based on written record or mother's self-
report?
El Written record
Mother's self-report
5. •Does your child have a usual source of dental care?
11 Yes
11 No
6. •Has (child's name) had a blood test for lead poisoning? If yes, ask about result of test.
• No
El Yes - result was negative
O Yes - result was positive
• Don't know
7. +What is the child's current weight? (Please weigh child.)
lbs. .1°z.
n Client Report
111 Nurse Home Visitor Measurement
8. • What is the child's current height? (Measure child head to toe.)
- linches
1-1 Client Report
n Nurse Home Visitor Measurement
9. +What is the child's current head circumference? (Measure head circumference)
-I centimeters
n Client Report
n Nurse Home Visitor Measurement
© Copyright 2016 Nurse-Family Partnership, All rights reserved. Page 2 of 5
Revised December 2076

• •
Breastfeeding:
10. •Has your child ever had breast milk?
ri Yes
O No (Skip to 15)
11. Does your child continue to get breast milk?
O Yes (Skip to 13)
fl No
12. How old was your child when s/he stopped getting breast milk?
E Less than one week (Skip to 15)
O One week or more; specify number of weeks: - I weeks (Skip to 15)
13. Is your child still exclusively receiving breast milk?
O Yes (Skip to 15)
O No
14. Until what age was your child fed exclusively breast milk (no water, juice, formula, cereal or
other solids)?
weeks
Safe Sleep: Questions 15, 16, and 17 should only be completed at Infancy 6 and 12 months;
otherwise please select "N/A"
15. *Howoften do you place your infant to sleep on their back?
n Always
O Sometimes
n N ever
fl N /A
16. •How often do you bed-share with your infant?
O Always
O Sometimes
O Never
O N/A
17. •How often does your infant sleep with soft bedding?
• Always
E Sometimes
O Never
E N/A
C Copyright 2016 Nurse-Fatnily Partnership. All rights reserved. Page 3 of 5
Revised December 2016

18. •Does your child have health insurance coverage?
El Yes (If yes, which type of health insurance do you use when you take your child for
medical care; please check all that apply)
n Medicaid
O CHIP
fl Tri-Care
El Private
ri Other (please specify)
O No
To be completed by the Nurse Home Visitor:
Developmental Delay
19. Please provide Ages and Stages scores for the child:
ASQ:SE Version used: E ASQ:SE D ASQ:SE2
ASQ:SE Questionnaire used: 6 months 12 months 18 months 24 months
ASQ:SE Total
El Child not eligible for screening at this time because child is receiving services
Parent declined further screening
Squires, J., Twombly, E., Bricker, D. & Potter, L. (2009). ASQ-3 User's Guide 3. 1 Ed. Baltimore, MD: Paul H.
Brookes Publishing Co, Inc.
Please complete the following after the home visit:
20. •Are you aware of any referral of mother/family to social services for child abuse, neglect or
other reasons since the child's birth?
n Yes Date of Referral: / (month/day/year)
Abuse EI Neglect 0 Other (please specify reason)
Date of Referral: (month/day/year)
El Abuse Neglect El Other (please specify reason)
Date of Referral: / / (month/day/year)
Abuse fl Neglect Fl Other (please specify reason)
O No
21. .Did you (nurse home visitor) initiate referral of mother/family to social services for child
abuse, neglect or other reasons since the child's birth?
Ei Yes Date of Referral: (month/ day/year)
0 Abuse El Neglect El Other (please specify reason)
Date of Referral: / / _ (month/day/year)
1=1 Abuse 0 Neglect 0 Other (please specify reason)
Date of Referral: / / _ (month/day/year)
LI Abuse LI Neglect 0 Other (please specify reason)
El No
© Copyright 2016 Nurse-Family Partnership. All rights reserved. Page 4 of 5
Revised December 2016

H.O.M.E. Inventory (to be completed at Infancy 6 months and Toddler 18 months ONLY)
The H.O.M.E Inventog is optional and NOT required by NFP. Some agencies are required by their state to
complete the H.O.ME to fulfll state funding requirements.
22. •Please provide the Infant/Toddler H.O.M.E. Inventory scores below:
6 months 18 months
Parental Responsivity
Acceptance of Child
Organization of the Environment
Learning Materials
Parental Involvement
Variety in Experience
TOTAL SCORE
Caldwell, B. M., & Bradley, R. H. (2003). Home Observation for Measurement of the Environment Inventory:
Administration Manual. Little Rock, AR.
© Copyright 2016 Nurse -Family Partnership. All rights reserved. Page 5 of 5
Revised December 2016

Clinical IPV Assessment F y
Pannership
Mflpe, nne-nre Mmati .4.reee
Client ID Client Name DOB
Date Nurse Home Nurse Home
Visitor ID Visitor Name
D 5111-7th Pregnancy Visit o12 Weeks Post-Partum oChild 16 Months EIPRN
Please circle how many times your partner (or ex-partner) did each of these things in the past 12 months.
1. Has your partner (or ex-partner) ever physically 1. Examples:
hurt you in the past 12 months? Pushed, grabbed or shoved?
1. Never Kicked, hit, or shaken?
2. Rarely Choked or restrained?
3. Sometimes Injured in some way?
4. Often
5. Frequently
2. Has your partner (or ex-partner) ever insulted 2. Examples:
you in the past 12 months? Called you names?
1. Never Humiliated you in front of other people?
2, Rarely Bullied or criticized you?
3. Sometimes Said you would be nothing without him/her?
4. Often Destroyed something important to you?
5. Frequently
3. Has your partner (or ex-partner) ever threatened 3. Examples:
to harm you in the past 12 months? Threatened you with a weapon?
1. Never Threatened to harm or kill you?
2. Rarely Left threatening or offensive emails or texts?
3. Sometimes Followed you and watched you?
4. Often Harassed you over the phone?
5. Frequently
4, Has your partner (or ex-partner) ever screamed 4. Examples:
or cursed at you in the past 12 months? Threatening or disrespectful words
1. Never Words that create fear or a sense of danger
2. Rarely
3. Sometimes
4, Often
5. Frequently
HITS @copyright Dr. Kevin Sherin 2005
Used and adapted with permission
CD Copyright 2017 Nurse-Family Partnership. All rights reserved.
Revised April 2017

5. Have you been forced to have any kind of 6 Examples:
sexual activity by your partner (or ex-partner)? Forced to have sex?
Made you take part in a sex act that made you
Yes0 NoD feel uncomfortable?
Forced you to do sexual things that you didn't
want to do?
6. Has your partner (or ex-partner) ever done 6.Examples:
things to try and control your thoughts, feelings Refused to let you leave the house?
or actions? Told you where you could go or who you could
see?
YesID No0 Refused to give you access to money?
Kept you from getting health care when you
needed it?
Kept you from talking to or seeing your family
members and friends?
Blamed you for his/her problems?
7. Has there ever been a time when the actions of 7.Examples:
your partner (or ex-partner) made you worried Threatened to harm or kill the child(ren)?
about the safety of your child(ren)? Took or threatened to take your child(ren) and
not return them to you?
Yes1=1 NoE Physically or sexually hurt your child(ren)?
Took the child(ren) to unsafe places (e.g. meth
house, bar)?
Screamed or yelled at the child(ren) and/or
called them names?
Blamed the child(ren) for his/her problems?
8. Are you now, or have you ever been afraid of,
your partner (or ex-partner)?
Yes ED No ID
Nurse Only
If you are entering a 'PRN" assessment, please select one of the following reasons:
DDelayed "Make-up" Assessment
ElAdditional Assessment
Scoring
Questions 1-4: Total
*If score is greater than 8 indicates risk of 1PV
Questions 5 -8: Any marked yes?
*Any Yes response indicates risk of 1PV
If Using State-Mandated Alternate IPV Screening Tool:
Indicate tool (select one):
D Abuse Assessment Screen (AAS)
D Abuse Within Intimate Relationships Scale (AIRS)
0 Copyright 2017 Nurse-Family Partnership. All rights reserved.
Revised April 2017

Maternal Health Assessment: Nutse Farn1y
Pregnancy-Intake Partnership
fii‘oing - Fent-Time ParrAll Succeed.
Client ID Client Name DOB
Date Nurse Home Nurse Home
Visitor ID Visitor Name
Obstetrical History
I have some questions about your pregnancy history. You do not need to answer any questions that
make you uncomfortable. I think most of these questions are fairly easy to answer and the
information will allow me to be more helpful to you.
1. +How many live births have you had?
2. +Are you going to a clinic or doctor during your pregnancy?
pi Yes
E No (skip to 4)
3. • How many weeks pregnant were you when you first started getting prenatal care for this
pregnancy?
I wks.
4. •What have you been told is your due date (EDD)?
I EDD
General Health History
Now I am going to ask you some questions about your overall health and problems.
5. Do you have a history of any health concerns? (please check all concerns that apply)
ri Heart problems 0 pre-pregnancy El gestational
n High blood pressure 0 pre-pregnancy 0 gestational
fl Diabetes n pre-pregnancy P1 gestational
pi Kidney disease pre-pregnancy 1-1 gestational
fl Chronic urinary tract infections E pre-pregnancy n gestational
1-1 Chronic vaginal infections E pre-pregnancy ri gestational
El STI 0 pre-pregnancy 0 gestational
0 Epilepsy
ri Sickle cell disease
O Chronic gastrointestinal diseases, e.g., Crohn's Disease, ulcers
ri Asthma/other chronic pulmonary disease
ri Genetic disease/Congenital anomalies
1-1 Mental health
0 Diagnosed Depression
ri Diagnosed Bipolar
fl Diagnosed Schizophrenia
fl Diagnosed Addiction
pi Alcohol
F7 Other drug use
O Other (Identify)
1:0 Copyright 2015 Nurse-Family Partnership. All rights reserved. Page 1 of 3
Revised November 2015

6. •What is your height?
ft. in.
7. •How much did you weigh before you became pregnant?
lbs.
8. *What is your current weight? (Please weigh client)
i lbs.
Personal Beliefs
Now I would like to ask for your opinion about some things. Please listen to each of the following
statements and tell me how strongly you agree or disagree with each one. Be as accurate and honest
as you can; there are no right or wrong answers.
9. 1 have little control over the things that happen to me.
• Strongly agree
E Agree
0 Disagree
O Strongly disagree
10. There is really no way I can solve some of the problems I have.
O Strongly agree
El Agree
n Disagree
ll Strongly disagree
11. There is little I can do to change many of the important things in my life.
E Strongly agree
• Agree
ri Disagree
r7 Strongly disagree
12. I oftenfeel helpless in dealing with the problems of life.
fl Strongly agree
fl Agree
O Disagree
E Strongly disagree
13. Sometimes I feel that I'm being pushed around in life.
O Strongly agree
D Agree
E Disagree
pi Strongly disagree
14. What happens to me in the future mostly depends on me.
17 Strongly agree
D Agree
O Disagree
n Strongly disagree
C Copyright 2015 Nurse-family Partnership. All rights reserved, Page 2 of 3
Revised November 2015

15. I can do just about anything I really set my mind to do.
n Strongly agree
O Agree
D Disagree
n Strongly disagree
C Copyright 2015 Nurse-Family Partnership, All rights reserved. Page 3 of 3
Revised November 2015

a _ Kase-Tarnity
Partnership
114ing Ferojime flavor Sward .
Nurse-Family Partnership Client Survey - 1 year Postpartum
Instructions: Mark the box on the right that shows how much you
agree or disagree with each statement. Your responses are to u
confidential—your nurse will not see your answers. g
461 Ac'
1. My nurse helps me see my strengths.
2. My nurse helps me think carefully about things so I can make
good decisions.
3. My nurse and I work well together.
4. My nurse helps me feel good about becoming/being a mother.
5. My nurse helps me find ways to reach my goals.
6. My nurse and I find ways to recognize my successes.
7. My nurse helps me with my health.
8. My nurse helps me with the health of my baby.
9. My nurse respects my culture, values and beliefs.
10. My nurse talks with me about what will work for me. She does
not tell me what to do.
11. My nurse helps me figure out how to get the services I need.
12. My nurse encourages me to go to supportive friends and family
when I need help.
Please Tell Us About You:
1. Why are you participating in this program?
Comments:
Thank you for taking the time to give your feedback.
Adapted with permission from the Strengths-Based Practice Inventory. B Green, C McAllister and J Tarte (2004)
C.c) Copyright 2012 Nurse-Family Partnership. All rights msci-veil,

-Family
Patient Health Questionnaire-9 (PHQ-9) Partnership
Hdping Firrt-75,, Pdrratr Snrord •
Client ID Client Name DOB
Date Nurse Home Nurse 1-Tome
Visitor ID Visitor Name
Check one: E Intake 0 Pregnancy 0 Infancy 0 Infancy L Infancy
36 Weeks 1-8 Weeks 4-6 Months 12 Months
E Additional (PRN)
Over the last 2 weeks, how often have you been bothered by any of the following problems?
1. *little interest or pleasure in doing things 7. +Trouble concentrating on things, such as
0 0 - Not at all reading the newspaper or watching television
O 1 - Several days 0 0 - Not at all
O 2 - More than half the days 0 1 - Several days
0 3 - Nearly every day 0 2 - More than half the days
fl 3 - Nearly every day
2. +Feeling down, depressed or hopeless
E 0 - Not at all 8. +Moving or speaking so slowly that other
0 I - Several days people could have noticed? Or the opposite —
0 2 - More than half the days being so fidgety or restless that you have been
n 3 - Nearly every day moving around a lot more than usual
0 0 - Not at all
3. +Trouble falling or staying asleep, or sleeping O 1 - Several days
too much 0 2 - More than half the days
0 0 - Not at all 0 3 - Nearly every day
EI 1 - Several days
LI 2 - More than half the days 9. *Thoughts that you would be better off dead
ElIl 3 - Nearly every day or of hurting yourself in some way
o - Not at all
4. +Feeling tired or having little energy E 1 - Several days
O 0 - Not at all 0 2 - More than half the days
E 1 - Several days E 3 - Nearly every day
0 2 - More than half the days
O 3 - Nearly every day Add all individual item scores to determine
Total Score:
5. *Poor appetite or overeating
fl o - Not at all 10. If you checked off any problems, how
O 1 - Several days difficult have these problems made it for
O 2 - More than half the days you to do your work, take care of things at
0 3 - Nearly every day home, or get along with other people?
n Not difficult at all
6. *Feeling bad about yourself— or that you are E Somewhat difficult
a failure or have let yourself or your family 0 Very difficult
down 7 Extremely difficult
O o - Not at all
O 1 - Several days Developed by Drs. Robert L. Spitzer, Janet B.W.
0 2 - More than half the days Williams, Kurt Kroenke and colleagues, with an
0 3 - Nearly every day educational grant from Pfizer Inc. No permission
required to reproduce, translate, display or distribute.
Revised April 2015 Page 1 of 2

0 •' -Farriily
Partnership
Referrals to Services Helping Firojime lirreffir Swam
Client ID Client Name DOB
Date Nurse Horne Nurse Home
Visitor ID Visitor Name
REFERRALS:
Client Child Services
Financial Assistance
1. TANF/Welfare
2. Food Stamps
3. Social Security/Social Security Disability
• 4. Unemployment Benefits
• 5. Subsidized Child Care
Crisis Intervention
6. Intimate Partner Violence
7. Child Protective Services
• Mental Health
8. Mental health treatment or therapy
9. Relationship counseling
Substance Abuse
10. Smoking Cessation
11. Alcohol Abuse
12. Drug Abuse
Health Care
13. Medicaid
14. SCHIP (State Children's Health Insurance Program)
15. Private insurance
16. Military insurance (Tricare)
17. Indian Health Service
18. Children with Special Health Care Needs
19. Primary care provider - sick client
20. Primary care provider - well client - prenatal
• 21. Primary care provider - well client - postpartum
22. Primary care provider - well client - well-women care
23. Primary care provider - sick child
24. Primary care provider - well child
25. Developmental Disabilities (Adult)
26. Early Childhood Intervention
27. WIC
28. Child Care Referral Services
29. Job Training and Employment
30. Housing
31. Transportation
32. Injury Prevention (car seat, smoke alarms, etc.)
33. Child birth education classes
0 Copyright 2016 Nurse-Family Partnership. All rights reserved. Page 1 of 2
Revised October 2016.

-Family
:) \ Partnership
Referrals to Services Helping Firtt-lime AMMO SIM -Md.
Client Child Services
34. Lactation support
Educational Programs
35. GED/Alternative High School
36. Further education beyond high school
37. Charitable Services (food bank, clothing, furniture, etc.)
38. Legal Services
39. Paternity
40. Child Support
41. Adoption Services
42. Dental Services
43. Other, specify:
© Copyright 2016 Nurse-Family Parthership. All rights reserved, Page 2 of 2
Raised October 2016

0 E..
STAR Framework a • • PartnershiO
11414 Fiat-Timm Roma Swerdk
Client ID Client Name
Date of Visit Nurse Home Nurse Home
Visitor ID Visitor Name
Check one: ] Initial D Pregnancy n Infancy n Infancy 1-1 Toddler
36 Weeks 8 Weeks 12 Months 18 Months
Personal Health
1. Substance Use and Abuse 2. Pregnancy Complication or 3. Developmental and
Chronic Illness Intellectual Disability
+Risk Level +Risk Level • Risk Level
0 0 – Low (Skip to Q2) El 0 – Low (Skip to Q3) E - Low (Skip to Q4)
El 1 - Moderate E 1 - Moderate El 1 - Moderate
El 2– High El 2– High E 2 – High
0 NA – Not Addressed D NA – Not Addressed El NA – Not Addressed
(Skip to Q2) (Skip to Q3) (Skip to Q4)
*Understands Risk /Needs +Understands Risk /Needs +Understands Risk /Needs
El Yes 0 Yes 0 Yes
0 No El No El No
+Stage of Change +Stage of Change +Stage of Change
PC – Pre-Contemplation 0 PC – Pre-Contemplation 0 PC – Pre-Contemplation
(Skip to Q2) (Skip to Q3) (Skip to Q4)
111C - Contemplation El C - Contemplation C - Contemplation
▪ P – Preparation P – Preparation El P – Preparation
El A – Action El A – Action El A – Action
M – Maintenance M – Maintenance M – Maintenance
E SE – Self Empowerment E SE – Self Empowerment E SE – Self Empowerment
+Friends/family support • Friends/family support • Friends/family support
goals goals goals
0 Yes E Yes El Yes
E No E] No El No
*Uses services to meet goals +Uses services to meet goals +Uses services to meet goals
fl Yes El Yes 0 Yes
1-1 No
El No El No
1
@2015 The regents of the University of Colorado, a body corporate. All rights reserved.

a Nuxse.--Farnily
STAR Framework Partnership
Ite{ping FIrrt-Time Parents Surreal
Maternal Role
4. Depression, Anxiety and 5. Caregiving Attitudes 6. Child Health and
other Mental Health Issues and Behaviors Development
*Risk Level *Risk Level *Risk Level
D 0 - Low (Skip to Q5) 0 0-Low (Skip to Q6) El 0 - Low (Skip to Q7)
O 1 - Moderate E I - Moderate 0 1 - Moderate
El 2- High E l 2 - High El 2- High
O NA - Not Addressed D NA - Not Addressed 0 NA - Not Addressed
(Skip to Q5) (Skip to Q6) (Skip to Q7)
*Understands Risk/Needs *Understands Risk/Needs +Understands Risk/Needs
D Yes E l Yes El Yes
0 No E l No 0 No
*Stage of Change *Stage of Change • Stage of Change
0 PC - Pre-Contemplation 0 PC - Pre-Contemplation 0 PC - Pre-Contemplation
(Skip to Q5) (Skip to Q6) (Skip to Q7)
▪ C Contemplation C - Contemplation ▪ C - Contemplation
▪ P - Preparation ▪ P Preparation ▪ P - Preparation
0 A - Action D A - Action El A - Action
El M - Maintenance El M - Maintenance ▪ M - Maintenance
0 SE - Self Empowerment El SE - Self Empowerment 0 SE - Self Empowerment
• Friends/family support • Friends/family support • Friends/family support
goals goals goals
El Yes El Yes 0 Yes
O No 0 No No
• Uses services to meet goals • Uses services to meet goals • Uses services to meet goals
O Yes 0 Yes El Yes
El No fl No 0 No
2
@2015 The regents of the University of Colorado, a body corporate. All rights reserved.

STAR Framework
Helping Pim -Mot Parrtdt Suerra •
Life Course
7. Child Care 8. Maternal Education and 9. Pregnancy Planning
Work
*Risk Level • Risk Level *Risk Level
ILI 0— Low (Skip to Q8) LO —Low (Sldp to Q9) 0 0 — Low (Skip to Q10)
E I - Moderate LI I - Moderate LI 1 - Moderate
2— High El 2— High LI 2—High
O NA — Not Addressed (Skip LI NA — Not Addressed (Skip LI NA — Not Addressed (Skip
to Q8) to Q9) to Q10)
*Understands Risk/Needs *Understands Risk/Needs *Understands Risk/Needs
0 Yes LI Yes LI Yes
El No El No LI No
• Stage of Change *Stage of Change *Stage of Change
0 PC — Pre-Contemplation LI PC — Pre-Contemplation 7 PC — Pre-Contemplation
(Skip to Q8) (Skip to Q9) (Skip to Q10)
El C - Contemplation El C - Contemplation LI C - Contemplation
7 P — Preparation El P — Preparation El P — Preparation
fl A — Action El A — Action 0 A Action
LI M - Maintenance - Maintenance El M — Maintenance
O SE — Self Empowerment E SE — Self Empowerment 0 SE — Self Empowerment
*Friends/family support • Friends/family support • Friends/family support
goals goals goals
LI Yes E Yes E Yes
0 No E No No
• Uses services to meet goals *Uses services to meet goals *Uses services to meet goals
El Yes LI Yes LI Yes
111 No El No El No
3
@2015 The regents of the University of Colorado, a body corporate, All rights reserved.

irse
STAR Framework Partnership
HeOing.First-Time Parents Succeed .
Family / Friends
10. English Literacy 11. Criminal Justice / Legal 12. Loneliness and Social
Limitations Issues Isolation
+Risk Level +Risk Level +Risk Level
E o — Low (Skip to Q11) LO—Low (Skip to Q12) flO—Low (Skip to Q13)
El 1 - Moderate O I - Moderate I: 1 - Moderate
0 2— High O 2— High fl 2— High
El NA — Not Addressed E NA — Not Addressed 1=1 NA — Not Addressed
(Skip to Q11) (Skip to Q12) (Skip to Q13)
+Understands Risk/Needs +Understands Risk/Needs +Understands Risk/Needs
0 Yes D Yes 0 Yes
No E No No
+Stage of Change +Stage of Change *Stage of Change
E PC — Pre-Contemplation PC — Pre-Contemplation El PC — Pre-Contemplation
(Skip to Q11) (Skip to Q12) (Skip to Q13)
LII C - Contemplation 0 C - Contemplation C - Contemplation
LII P Preparation fl P — Preparation P — Preparation
LI A — Action 0 A — Action A — Action
— Maintenance — Maintenance • — Maintenance
E SE — Self Empowerment O SE — Self Empowerment E SE — Self Empowerment
• Friends/family support • Friends/family support • Friends/family support
goals goals goals
Yes 0 Yes El Yes
El No O No No
• Uses services to meet goals +Uses services to meet goals • Uses services to meet goals
111 Yes 0 Yes pi Yes
0 No ▪ No 1-1 No
4
@2015 The regents of the University of Colorado, a body corporate. All rights reserved.

Nlif se -Family
STAR Framework Partnership
Ifelpi,gRrnJ5fl Suard
Environmental Health
13. Intimate Partner 14. Unsafe Family or Friend 15. Economic Adversity
Violence Network
*Risk Level *Risk Level
O O—Low (Skip to Q14) CO—Low (Skip to Q15) +Risk Level
0 1 - Moderate O 1 - Moderate 0 — Low (Skip to Q16)
O 2— High O 2— High 0 1 - Moderate
D NA — Not Addressed O NA — Not Addressed D 2— High
(Skip to Q14) (Skip to Q15) 0 NA — Not Addressed
(Skip to Q16)
*Understands Risk/Needs *Understands Risk/Needs *Understands Risk/Needs
O Yes O Yes 0 Yes
0 No 0 No 0 No
*Stage of Change *Stage of Change *Stage of Change
fl PC — Pre-Contemplation LI PC — Pre-Contemplation 0 PC — Pre-Contemplation
(Skip to Q14) (Skip to Q15) (Skip to Q16)
E c - Contemplation fl C - Contemplation
P — Preparation P — Preparation LI C - Contemplation
O A — Action fl A — Action EP — Preparation
O M — Maintenance E M — Maintenance fl A — Action
0 SE — Self Empowerment fl SE — Self Empowerment — Maintenance
D SE — Self Empowerment
•Friends/family support *Friends/family support
goals goals *Friends/family support
0 Yes O Yes goals
fl No O No 0 Yes
0 No
*Uses services to meet goals *Uses services to meet goals *Uses services to meet goals
D Yes 0 Yes 0 Yes
fl No ▪ No fl No
5
@2015 The regents of the University of Colorado, a body corporate. All rights reserved.

\urrFarni1y
STAR Framework Partnership
lielptng Flut.Tionl Ramo Swivel.
16. Homelessness and
Residential Instability 17. Environmental Health 18. Home Safety
+Risk Level +Risk Level +Risk Level
LO—Low (Skip to Q17) 0 0 — Low (Skip to Q18) o — Low (Skip to Q19)
El 1 - Moderate - Moderate O 1 - Moderate
D 2 — High 0 2— High 0 2 — High
O NA — Not Addressed NA — Not Addressed 0 NA — Not Addressed
(Skip to Q17) (Skip to Q18) (Skip to Q19)
+Understands Risk/Needs *Understands Risk/Needs +Understands Risk/Needs
01 Yes El Yes 0 Yes
El No O No 0 No
• Stage of Change *Stage of Change +Stage of Change
O PC — Pre Contemplation 0 PC — Pre-Contemplation 0 PC — Pre-Contemplation
(Skip to Q17) (Skip to Q18) (Skip to Q19)
El C - Contemplation D C - Contemplation ▪ C - Contemplation
P — Preparation ▪ P — Preparation ▪ P — Preparation
O A — Action 0 A Action El A — Action
▪ M — Maintenance — Maintenance M — Maintenance
0 SE — Self Empowerment D SE — Self Empowerment D SE — Self Empowerment
• Friends/family support +Friends /family support +Friends/family support
goals goals goals
fl Yes ID Yes fl Yes
0 No 0 No 0 No
• Uses services to meet goals +Uses services to meet goals *Uses services to meet goals
O Yes D Yes D Yes
▪ No 0 No 1-1 No
6
@2015 The regents of the University of Colorado, a body corporate. All rights reserved.

INurse-•arnily
STAR Framework Partnership
g4ing Furolime Aeolis Sward •
Health and Human
Services
19. Health Services 20. Well-Child Care 21. Use of Other
Utilization (Infancy/Toddlerhood Community Services
Only)
*Risk Level +Risk Level *Risk Level
D o - Low (Skip to Q20) LO- Low (Sldp to Q21) - Low
1:1 1 - Moderate El 1 - Moderate D I - Moderate
El 2 — High El 2 — High 11 2— High
El NA — Not Addressed Lii NA — Not Addressed El NA — Not Addressed
(Skip to Q20) (Skip to Q21)
*Understands Risk/Needs +Understands Risk/Needs *Understands Risk/Needs
El Yes El Yes El Yes
▪ No D No El No
*Stage of Change *Stage of Change *Stage of Change
El PC — Pre-Contemplation El PC — Pre-Contemplation I PC — Pre-Contemplation
(Skip to Q20) (Skip to Q21) C - Contemplation
▪ C - Contemplation El c - Contemplation ▪ P — Preparation
El P — Preparation El P — Preparation El A — Action
O A — Action El A — Action El M — Maintenance
▪ M — Maintenance El M - Maintenance El SE — Self Empowerment
SE — Self Empowerment 0 SE — Self Empowerment
*Friends/family support
• Friends/family support • Friends/family support goals
goals goals El Yes
El Yes LI Yes El No
El No No
*Uses services to meet goals
+Uses services to meet goals *Uses services to meet goals El Yes
D Yes E Yes El No
El No El No
7
@2015 The regents of the University of Colorado, a body corporate. All rights reserved.

• -Family
STAR Framework 0 Part'nership
/felting Firxr-Tirrte "brags Succeed
Global Protection Factors
• Overall, are any of the following factors present? (Check all that apply)
Keeps NFP Appointments
Engaged in NFP Program
El Has Psychological Resources
E Protects Her Health
Demonstrates Commitment to Protect Child
LII Social Support (Partner, Family, Friends)
111 U.S. Citizen or Legal Resident
8
@2015 The regents of the University of Colorado, a body corporate. All tights reserved.

- FamiIy
'artnership
Use of Government & Community Services lielping Finr-Tiror Palm, rSarrend ,
Client ID Client Name DOB
Date Nurse Home. Nurse Home
Visitor ID Visitor Name
*Record services used only at following time points:
Intake 1II Infancy 6 Months El Toddler 18 Months
Infant's Birth IIii1 Infancy 12 Months 111 Toddler 24 Months
Service Utilization Response Key:
2 =Client or child is currently receiving this service
3 =Service assessed by NHV as needed — NHV has previously made a referral for this service, but
the service is full, client or child is waiting for service, or service not available in area
4 =Service assessed by NHV as needed — NHV has previously made a referral for this service, but
the client refused the referral or did not take action for herself or her child
5 = Client or child received this service since the last time the form was completed, but is no longer
receiving this service.
6 = Service assessed by NHV as needed — NHV made referral for this service at the visit
Client Child Service
Financial Assistance
1. TANF/Welfare
2. Food Stamps
3. Social Security/Social Security Disability
4. Unem lo inent Benefits
5. Subsidized Child Care
Crisis Intervention
6. Intimate Partner Violence
7. Child Protective Services
Mental Health
8. Mental health treatment or therapy
9. Relationship counseling
Substance Abuse
10. Smoking Cessation
11. Alcohol Abuse
12, Drug Abuse
Health Care
13. Medicaid (The number is to be entered into the View/Edit Client Demographics
screen in ETO)
I Client Medicaid Number I Child Medicaid Number
14. SCHIP (State Children's Health Insurance Program)
15. Private insurance
16. Military insurance (Tricare)
17. Indian Health Service
18. Children with Special Health Care Needs
19. Primary care provider — sick client
20. Primary care provider — well client — prenatal care
© Copyright 2016 Nurse-Family Partnership. All rights reserved, Page 1 of 2
Revised October 2016

21. Primary care provider – well client – postpartum
Client Child Service
22. Primary care provider – well client – well-women care
23. Primary care provider – sick child
24. Primary care provider – well child
25. Developmental Disabilities (Adult)
26. Early Childhood Intervention ,
If 2 or 5 was selected, was the child evaluated within 45 days of referral?
L-1Yes LJ No
27. WIC (Supplemental Nutrition Program for Women, Infants and
Children)
28. Child Care Referral Services
29. Job Training and Employment
30. Housing
31. Transportation
32. Injury Prevention (car seat, smoke alarms, etc.)
33. Child birth education classes
34. Lactation support
Educational Programs
35. GED/Alternative high school
36. Further education beyond high school
37. Charitable Services (food bank, clothing, furniture, etc.)
38. Legal Services
39. Paternity
40. Child Support
41. Adoption Services
42. Dental Services
43. Other, specify:
a.
b.
C.
O Copyright 2016 Nurse-Family Partnership. All rights reserved. Page 2 of 2
Retired October 2016

Nunc-Famo
Baby's . Brain Partnership
Baby's brain is growing fast! At 12 months, the brain
will be much bigger than when baby was a newborn.
How much bigger do you think it will be at age 1?
How big will baby's brain be at age 6?
Your baby's brain is making links. The links connect the parts of baby's
brain. The links help baby think. They help baby grow and develop.
Brain growth during the first year helps baby learn to figure things out.
Some parents hope their child gets good grades. Some parents hope their
child is good at sports. Some parents hope their child will have lots of
friends.
My hopes for my baby:
C Copyright 2015 The Regents of the University of Colorado, a body corporate. All rights reserved. Page 1 of 2

Baby's Brain
Doing fun things builds baby's brain. New things help
the brain build more links.
Singing, talking, walking, dancing, laughing and
playing help baby learn. Baby learns to problem solve
by exploring the world.
0 Copyright 2015 The Regents of the University of Colorado, a body corporate. All rights reserved. Page 2 of 2