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Visit Date: October 20, 2021 ID Number: 153376
Visit Count: Children Served: 4 Community Health Worker: Asha

Consultation services Delivered

What type of Consultation was it? Phone or virtual consultation session
Did you make a Child Development Referral (Not Screening) * Answered: Yes
Get information on how to help me cover my basic needs (food – clothing – housing – medical attention) Answered: Yes

Healthy and Safe Environment Concerns

Is your home safe for children? : Answered: Yes
Safe Sleep: Answered: Yes
How to prevent the spread of illness: Answered: Yes

Child Development Concerns

Health Related Social Needs Concerns

HealthCare Concerns

How to help me cover my HRSN (e.g. food, transportation, housing, medical needs, employment). Answered: Yes
Coping with stressful situations. Answered: Yes
Resource-Referral Type(s).
Covid 19 Related Information
Consultation Duration

Start Time: 12:01 PM
End Time: 12:51 PM
Time Period: 45 mins

Goals

Progress Made Towards Goal?:
Goal Attained?
Goal attained

Notes for this Consultation

Required and completed provider intake with focus on preventing the spread of illness, safe sleep, home safe for children.