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Foster Care Screening Questionnaire
stagebrevcares
2024-01-09T12:01:46-05:00
Foster Care Screening Questionnaire
Parent Name 1
(Required)
Dr.
Miss
Mr.
Mrs.
Ms.
Mx.
Prof.
Rev.
Prefix
First
Middle
Last
Date of birth Parent 1
(Required)
MM slash DD slash YYYY
Parent Name 2
Dr.
Miss
Mr.
Mrs.
Ms.
Mx.
Prof.
Rev.
Prefix
First
Middle
Last
Date of birth Parent 2
(Required)
MM slash DD slash YYYY
Home Phone
(Required)
Email
(Required)
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
County:
(Required)
How did you hear about us?
(Required)
Minimum age range
(Required)
Newborn
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
TO
Maximum age range
(Required)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
Select your marital status
(Required)
- Marital Status -
Married
Single
Divorced
Other
What is your current home type:
(Required)
- Home Type -
Single family
Apartment
Condo
Living with relatives
What are the number of bedrooms?
(Required)
- Bedroom count -
1
2
3
4
5
6
7
8
9
What is the number of additional adults living in the home?
(Required)
Number of youth under 18 living in the home?
(Required)
List ALL members of your household (Anyone who lives in your home not already listed)
Name
First
Last
Relationship:
Date of Birth
MM slash DD slash YYYY
Name
First
Last
Relationship:
Date of Birth
MM slash DD slash YYYY
Name
First
Last
Relationship:
Date of Birth
MM slash DD slash YYYY
Name
First
Last
Relationship:
Date of Birth
MM slash DD slash YYYY
Name
First
Last
Relationship:
Date of Birth
MM slash DD slash YYYY
Name
First
Last
Relationship:
Date of Birth
MM slash DD slash YYYY
Do you have a vehicle that can hold your family and an extra child?
(Required)
- Vehicle Capacity -
Yes
No
Are you currently employed?
(Required)
- Job -
Yes
No
Do you all produce enough Income to support your family and an additional child if placed in your home?
(Required)
- Income -
Yes
No
Assistance from Government such as Food Stamps, Section 8 housing or unemployment?
(Required)
- Income -
Yes
No
(If yes, please explain)
Does anyone in the house have any arrests or felonies?
(Required)
- Income -
Yes
No
(If yes, please explain)
Have any of your household members lived out of the State of Florida in the past 5 years?
(Required)
Yes
No
If yes; Name of household member(s)
(Required)
List previous states in the past 5 years:
(Required)
Are you each U.S. citizens? If not, what is your status?
(Required)
Yes
No
Additional Details
Comments
This field is for validation purposes and should be left unchanged.
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