FOSTER PARENTS SPECIFIC INTEREST FORM129 – Variety Children and Family

Name:

First

Last

Phone#:

Interested in being a foster parent for children ages 0 -5 years

Yes

No

OR 6 – 17 years -

Yes

No

Number of Children preferred

Requesting max

Gender

Yes

No

Both

Child age range preferred

Will consider siblings:

Yes

No

Ethnic Or Tribal Preference ?:

Yes

No

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If Yes , What Ethnic Or Tribal Preference? :

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Physical Characteristics: - Will Consider - May consider - Will Not Consider

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Ambulatory

Will Consider

May Consider

Will Not Consider

Mild physical Disability

Will Consider

May Consider

Will Not Consider

Severe physical Disability

Will Consider

May Consider

Will Not Consider

Emotional Characteristics:

General Emotional Disorder

Will Consider

May Consider

Will Not Consider

History of Abuse/Neglect:

Will Consider

May Consider

Will Not Consider

History of sexual abuse

Will Consider

May Consider

Will Not Consider

Hyperactivity

Will Consider

May Consider

Will Not Consider

Depression

Will Consider

May Consider

Will Not Consider

Suicidal

Will Consider

May Consider

Will Not Consider

Behavioral Characteristics:

Severe Behavior Disorder

Will Consider

May Consider

Will Not Consider

Acting Out/Aggressive

Will Consider

May Consider

Will Not Consider

Sexually Active

Will Consider

May Consider

Will Not Consider

Drugs Abuse

Will Consider

May Consider

Will Not Consider

Tantrums

Will Consider

May Consider

Will Not Consider

Running Away

Will Consider

May Consider

Will Not Consider

Alcohol Abuse

Will Consider

May Consider

Will Not Consider

School Adjustment Problem

Will Consider

May Consider

Will Not Consider

Poor Social Skills

Will Consider

May Consider

Will Not Consider

Stealing/Lies

Will Consider

May Consider

Will Not Consider

Other Characteristics

Pregnant Teen

Will Consider

May Consider

Will Not Consider

Parenting Teen

Will Consider

May Consider

Will Not Consider

Sexually Confused

Will Consider

May Consider

Will Not Consider

Programs