Family Reunification Home Assessment Form
Basic Information
Case Number
Date of Assessment
Assessor Name
Family Name
Family Address
Contact Number
Children Details
Child(ren) Name(s)
Age(s)
Relationship to Caregiver
Caregiver Details
Caregiver Name
Date of Birth
Relationship to Child(ren)
Other Adults in Household
Home Environment
Type of Housing
No. of Rooms
Sanitation Facilities
Water Source
Safety & Security Concerns
Family Support System
Available Support Network
Access to Services (health, education, etc.)
Observations and Recommendations
Assessor's Observations
Recommendations
Follow-up Actions Required