Child Protective Services Visitation Report
Agency and Case Information
Date of Visit
Case Number
Child(ren) Name(s)
Social Worker Name
Location of Visitation
Participants
Parent(s) Present
Other Individuals Present
Observations
Visit Start Time
Visit End Time
Summary of Interaction
Child(ren) Behavior & Emotional State
Parent(s) Behavior & Responsiveness
Safety Concerns Noted
Recommendations
Summary / Recommendations
Signature
Social Worker Signature
Date