Screening Questionnaire for Foster Care Applicants - Community Partnership for Children

Caregiver 1 Name (First and Last)(Required)

Caregiver 1 Date of Birth(Required)

Caregiver 2 Name (First and Last)

Caregiver 2 Date of Birth

Prior Names (Including Maiden Name)

Caregiver 1 Email(Required)

Caregiver 1 Phone(Required)

Caregiver 2 Email

Caregiver 2 Phone

Current Address(Required)

Years at This Address(Required)

Previous Address

Years at This Address

Please List All Addresses For the Last Five Years

Do You Have Any Immediate Plans to Move?(Required)

Yes

No

Is Your Residence Currently in Foreclosure?(Required)

Yes

No

Number of Bedrooms in Home(Required)

Number of Bathrooms in Home(Required)

Please List All Household Pets

Can You Provide Proof of Rabies Vaccinations, if Applicable?

Yes

No

Do You Have a Pool, or Live on a Body of Water?(Required)

Yes

No

List ALL members of your household (anyone who lives in your home-do not include caregivers) and frequent visitors: Name, Age, and Relationship to You

Have you, anyone in your household, or a frequent visitor ever been arrested?(Required)

Yes

No

If applicable, please provide: name at time of the offense, city of arrest, date, offense, and outcome.

Have you or anyone in your household ever been involved in an investigation for abuse or neglect in the State of Florida or any other State? *This means even if the report is unfounded!(Required)

Yes

No

If applicable, please explain:

Have you ever applied to any other agency or State to be an adoptive or foster parent(s)?(Required)

Yes

No

If yes, what agency, and where?

Are you mainly interested in foster care or adoption?(Required)

Foster Care

Adoption

What is your motivation to foster?(Required)

What age group and/or gender are you interested in fostering?(Required)

How many children are you interested in fostering?(Required)

How did you hear about us?(Required)

What agency are you choosing to be licensed with?(Required)

Does the prospective foster parent(s) have a need for special accommodations?(Required)

Yes

No

If applicable, please explain:

Foster Parent Screening Questionnaire

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