FOSTER PARENT(S) APPRAISAL 119 – Variety Children and Family

NAME:

ADDRESS:

PHONE NUMBER :

TRIBE:

RELIGION:

RECOMMENDED CAPACITY(GIVE AGES PREFERED):

GENDER :

Male

Female

HOUSE HOLD MEMBERS :

there are more House hold Members, Please indicate all names on a separate Page (1)

MONTHLY INCOME:

Mother/Father: i-Le

( Total Income )

TOTAL MONTHLY EXPENSES :

( In Words ):

DATE OF INTERVIEW:

LOCATION:

EVALUATOR:

TITLE:

Phone

( BACKGROUND INFORMATION ON FAMILY MEMBER ) - WIFE

HUSBAND:

(OCCUPATION) - WIFE :

HUSBAND:

(DATE AND PLACE OF BIRTH) - WIFE :

HUSBAND:

( HOW WAS YOUR CHILDHOOD? ) - WIFE :

HUSBAND:

(SIBLINGS:) - WIFE

HUSBAND:

SCHOOL EXPERIENCE :

TEENAGE YEARS:

MAJOR ILLNESS/TRAGEDIES :

CHILD ABUSE :

DEATH :

(MARITAL HISTORY) - * HOW DID YOU MEET?

HOW LONG HAVE YOU BEEN MARRIED?

(PREVIOUSLY MARRIED?) - WIFE :

HOW LONG ?

(PREVIOUSLY MARRIED?) - HUSBAND :

HOW LONG ?

WHAT PROCESS DO YOU USE TO MAKE FAMILY DECISIONS?:

WHAT PROCESS DO YOU USE TO RESOLVE CONFLICTS? :

FAMILY ACTIVITIES :

RELIGIOUS INVOLVEMENT :

( EDUCATION AND EMPLOYMENT: COLLEGE/SECONDARY SCH/TRADE SCHOOL/JOBS/BUSINESS) - WIFE :

HUSBAND :

(EMOTIONAL AND PHYSICAL HEALTH) - HOW WOULD YOU DESCRIBE YOUR PERSONALITY? - WIFE :

HUSBAND :

(YOUR OUTLOOK ON LIFE) - WIFE:

HUSBAND :

(SPECIAL TALENTS AND HOBBIES) - WIFE:

HUSBAND :

HISTORY OF ALCOHOL OR DRUG ABUSE IN FAMILY?) - WIFE:

Casual

Moderate

Serious

HUSBAND

Casual

Moderate

Serious

(FAMILY RELATIONSHIP WITH CHILDREN) - DO YOU HAVE CHILDREN?

HOW MANY ?

WHAT ARE YOUR EXPECTATIONS OF YOUR CHILDREN/FOSTER CHILDREN?

WHAT IS YOUR DISCIPLINE STYLE?

DESCRIBE YOUR HOUSE RULES:

INTERESTED IN ADOPTION?

YES

If Yes , Do you want the adoption open or Closed ? ( Open ) ( Closed )

(SOCIAL WORKER/CASE MANAGER’S EVALUATION) - HOME :

OBSERVED APPRAISAL OF FAMILY INTERACTION :

Name

First

Last

GENERAL IMPRESSION & RECOMMENDATIONS :

SIGNATURE:

DATE:

If you are human, leave this field blank.

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