Youth Name: ________________________________________ Date: _______________________


In an effort to be sure that your child is bringing home the skills he is learning here, we ask that you complete this form and return it to staff at the end of each home pass. Please use the back of this form to describe any problems or incidents.

1. Did he comply with house rules?

YES                                        NO

2. Did he obey his curfew and/or return home at a reasonable time?

YES                                        NO

3. Was he truthful to you the whole time?

YES                                        NO

4. Did he remain sober & refrain from using alcohol or illegal substances?

YES                                        NO

5. Did he take all of his meds?

YES                                        NO

6. Overall, how would you rate his behavior on this visit?

Awful!                        Poor                 Manageable                 Good               Excellent


Personal Goals





Parent/Family Member/Legal Guardian: Please sign and return this form to a New Haven Staff Member at the end of your visit.   


Family Member’s Signature: ______________________________________

Please explain any negative incident(s) or unacceptable behavior:




Thank you!