474-000-320
Applicants:
Address:
County:
Telephone: Work: (area code)
Home: (area code)
Race:
Date of Application: Date of Approval:
Prepared by: Name
Position
Unit
Telephone
I. Summary of Agency Contacts
A. Description of Contacts
1. Initial contact date
2. Referral source
3. Prior contacts or studies by this agency or others.
B. Interviews held: date, place, who attended
C. Participation in foster or adoptive training: date, place
D. Self-study completed? Yes ___ No ___
II. Background and Personality of Applicants
A. Wife
1. Birthdate, age
2. Education
3. Current position and future career goals
4. Personality/maturity
5. Family background including relationships to siblings and extended family members
6. Significant life experiences
7. Social problems, including drug, alcohol, legal, etc. and effect on present functioning
B. Husband (same as above)
C. Children
1. Name, birthdate, grade level
2. Description of child (abilities, interests, personality, special needs)
3. Child's perception of foster care/adoption and ability to relate appropriately
III. Marriage
A. Previous marriage(s)/length of present marriage
B. Courtship
C. Current functioning
1. Decision-making process
2. Resolution of conflicts
3. The marital relationship
4. Attitudes toward the spouse's family
5. Readiness to foster/adopt and resolution of fertility problem (if any)
IV. Family Life Style
A. Work and play: interests, activities, hobbies
B. Religion
C. Living arrangements
1. Description of home
2. Sleeping arrangements
D. Income and financial management
1. Income
2. Ability to live within the income, money-management
3. If adoption - Insurance (including medical)
4. Unusual circumstances/expenditures
E. Community resources and support systems
1. Extended family and friends
2. School (including special education)
3. Churches
4. Medical
5. Other
F. Changes anticipated in life-style after a child is placed
V. Parental Experiences
A. Families with children
1. Parenting style and experience with children
2. Nurturing style
3. Methods of discipline
4. Goals and aspirations for children
5. Needs which children are expected to fulfill for parents
6. Understanding of and ability to meet child's physical and emotional needs
VI. Motivation to Foster or Adopt Children
A. How and when did the intention to adopt or foster come about
B. Feelings of other family members, including children, about the decision to adopt/foster children
C. Attitudes regarding birth parents and child's family history, including contact with the birth or foster family
D. Ability to work with the agency
E. Interest in openness in adoption
F. Plans for assimilating the child into the family, including -
1. Social differences
2. Handicapping condition
3. Ethnic/racial differences
4. Displacement of older children already in the family
G. If adoption, how will the child be told of his/her adoption and background
H. The family's understanding of and plan to assist the child to value his/her family and cultural background
VII. References
VIII. Medical report, including -
A. Identification of any condition which may be expected to affect parenting ability, either as a strength or weakness
B. Treatment plan
IX. Licensing, if applicable, including -
A. Law enforcement check
B. Central Registry check
X. Evaluation - worker perception of the physical, emotional, and intellectual aspects of the applicants; major strengths/limitations, ability of family to accept a child different from selves; flexibility; summary of the self-study and adoption and/or foster parent training experience, if any
XI. Statement of approval/disapproval and reason for the decision, including -
A. Type of child
1. Age range
2. Sex
3. Race
4. Physical handicap
5. Emotional handicap
6. Learning disabilities
7. Mental retardation
8. Child in need of placement with siblings
9. Medical risk
10. Legal risk and/or fos-adopt
11. Child in need of openness
XII. Signatures
(Worker) Date
(Supervisor) Date
(Rev. March 14, 1988)