HOME VISIT SAFETY CHECKLIST
The prospective client seeking in-home service fills out the form prior to the onset of service. The information is used to make a determination to proceed with in-home counselling. Mileage and travel fees apply.

NAME _____________________  DATE of REQUEST ___________ 
WHEN DO YOU WANT TO BEGIN SERVICE? __________ TIME REQUESTED________
TYPE OF SERVICE AND WHO WILL ATTEND (individual, couple, family) _____________  
ADDRESS /CLIENT _________________________________________________
ADDRESS WHERE SERVICE WILL BE DELIVERED ____________________________________________
PHONE _______________   ALT _________________  EMAIL ________________
1. Is there parking close to the residence where service will be delivered? Is it free?

2. Is there a safe walkway to the place of service that is well lit after dusk? Is it shovelled?
3. Is there a quiet space within the residence that is private and suitable for service?
4. Are there pets in the home? What kind? Will they be gated or removed during service?
5. Who else lives in the home? Will the person(s) be in the home when counselling takes place?
5. Where is the entrance of the residence?
6. Is there smoking or strong scents in the area proposed for counselling?
7. Is there anything else that may be of importance to mention?
NOTES: paste the following link into your search bar for mileage rate (.54/km)
http://www.njc-cnm.gc.ca/directive/index.php?lang=eng&svid=97-(