Weekend Miracles® Host Family Weekend Report

*First Name:

*Last Name:

*Phone:

Your E-mail:

*Weekend Miracles Child Name:

*Date(s) of Visit(s) in Your Home:

Hours:

1. What did you and your host child do together?

2. How do you think the visit went?

3. How did the child respond? Did s/he enjoy/participate/engage with you?

4. Did you learn anything new or special about your child during this visit?

5. How did your host child respond to your family members? Were there any difficulties?

6. Do you have any concerns regarding your host child's behavior and attitude during the visit?

7. Do you have any unmet needs for support? Are there any concerns you would like to discuss with the social worker?

8. Please provide best time to reach you and preferred method of contact (email, phone, etc.)

9. Are you involved in any planned interventions or activities on behalf of your child (i.e. behavior plan, IEP)? What was the outcome this week?

10. What advocacy efforts have you engaged in this week?

11. Is there someone you would like Kidsave staff to contact on the child's behalf? If so, please provide name(s) and contact information.

12. What is the date of your next planned meeting?

A copy of this completed form will be sent to Kidsave.
You will also receive a confirmation copy by return email for our records.