Home Visit Form
1. Contact details of potential home
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Submit
2. Is the home suitable to house a parrot?
Occupation
Employer
Can the job role have an impact on this adoption? e.g. Long house or on call work?
What kind of setup do they intend on having?
Cage within home
Aviary
Has a cage been sourced for a parrot already?
Yes
No
Other
Any concerns regarding the layout or placement? Please note where cage is going to be situated and suitability.
How long will the parrot have outside their cage each day?
Far enough away from...
Cleaning supplies
Bathrooms (aerosols/perfumes)
Air fresheners/incense
Do they own their own home?
Yes
No
If the answer to the above is no, do they have permission to have a bird in the house?
Yes
No
Do the potential adopters have any of the following health conditions: allergies, respiratory conditions, long-term health conditions or is anyone in the household immunocompromised?
Yes
No
If yes, please give details about any medical conditions and remedies already in place
If yes to above, please specify
Are the potential adopters aware of dust/HEPA filters which are available which may help?
Yes
No
Are there any smokers in the house (including vaping)? If yes, please detail
Do they already have another bird or birds in the house?
Yes
No
If there are other birds in the house please specify for each: Age Where obtained from and how long have had Ever been kept with other birds (either in the house or at previous home/breeder/pet shop where they came from) Have they been 'boarded' (if yes, where) Are they fully feathered or not Is there any evidence of health issues (currently or in the past) Have they ever been seen/treated by a vet, for what reason and was there any treatment required? Ask the adopter to supply pictures of any birds currently in the house.
If there are any small children or animals in the house, please specify. Please include ages of children and species/ages of animals.
If the answer to the above is yes, is it possible to have the animals segregated during interaction times?
3. Knowledge and experience with birds prior to this visit
Do the potential adopters have experience with birds?
Yes
No
Other
If yes, please specify. Include how long they have had birds. If no longer, what happened?
Do the potential adopters have any of the following health conditions: allergies, respiratory conditions, long-term health conditions or is anyone in the household immunocompromised?
Yes
No
How do the potential adopters plan to manage holidays?
Do they drive? If no, how to they plan to get to the vets in times of emergencies?
4. Checklist
Has each attribute of the checklist been discussed?
Yes
No
Are there any disease testing requirements for this household?
Yes
No
If the above answer is yes, please detail below
Does the household have adequate smoke/carbon monoxide detection equipment installed?
Yes
No
Were all members of the household present during the visit?
Yes
No
If not, why not?
Did the potential adopter ask any questions which the home visit team were unable to answer?
Any additional information worthy of note?
Home visit donation received
Yes
No
Names of home visit team participants
Recommendation from home visit team regarding adoption
Approve
Decline
Defer to directors
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit to Directors
Should be Empty: