Substance Exposure Child Home Visit Form
Child Information
Child Name
Date of Birth
Caregiver Name
Relationship to Child
Home Visit Details
Date of Visit
Time of Visit
Visit Address
Substance Exposure History
Substances Child Was Exposed To
Description of Exposure
Current Home Environment
Home Description/Observations
Child’s Health and Behavior
Physical/Health Observations
Behavioral Observations
Caregiver Support & Needs
Support or Resources Needed
Conclusion
General Comments & Next Steps