ࡱ>    n @ cbjbjʚʚ $>&"8:bNcd+N<RRR-tm<'))))))$x,R.)e--)RR<+CCCRR'C'CCCRh 0z).C  R+0+Cz/z/CdN@z/QC))tR}dt3R}INITIAL FOSTER HOME/ADOPTION EVALUATIONAGENCY NAME: FORMTEXT      AGENCY LICENSE NUMBER: FORMTEXT      Date of Report: FORMTEXT      Use Tab key to advance to the next field. Use Enter key to add additional lines within a field. For Items #7 Social History, #8 Health, #10 Children answer all items for each individual person together and repeat as necessary for additional people. 1.FOSTER HOME INFORMATION:Foster home name: FORMTEXT      Foster home license number, (CF # or CG#): FORMTEXT      Address: FORMTEXT      Telephone number (s): FORMTEXT      Driver s license number; verification of valid driver s license: FORMTEXT      Members of the household (Name, Role, Date of Birth): FORMTEXT      2.SOCIAL WORK CONTACTS: (Date, Location, Persons Interviewed) FORMTEXT      3.DIRECTIONS TO HOME: FORMTEXT      4.COMMUNITY:Type of community (rural, urban, etc.): FORMTEXT      Socio-economic makeup: FORMTEXT      Racial/cultural makeup: FORMTEXT      Availability of recreational facilities: FORMTEXT      School system, including special education: FORMTEXT      Hospitals and medical care: FORMTEXT      Availability of churches, noting family s choice of church: FORMTEXT      5.HOME:Description of home and rooms, noting condition, layout, appearance: FORMTEXT      Explanation of proposed sleeping arrangements for family members and foster children: FORMTEXT      Description of play space: FORMTEXT      Any safety considerations, including weapons or pets: FORMTEXT      If there are pets, does the pet have current vaccinations?  FORMDROPDOWN Is the animal licensed if that is required by the municipality where the family lives? FORMDROPDOWN Are there smoke detectors on each floor and between each sleeping area and the rest of the home? FORMCHECKBOX  Yes  FORMCHECKBOX  NoIs there a carbon monoxide detector installed as recommended by the manufacture? FORMCHECKBOX  Yes  FORMCHECKBOX  NoAny water hazards on or near premises and an explanation as to how applicant would safeguard children from them: FORMTEXT      Water, sewer, refuse arrangements, health inspection results if applicable: FORMTEXT      Water temperature tested, less than 120o Fahrenheit? FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMTEXT      Emergency Procedures form completed: FORMTEXT      Adequacy of the house, property, neighborhood, schools and community for the purpose of fostering as determined by an on-site visit: FORMTEXT      Means of transportation; i.e. ages and makes of automobiles, accessibility of public transportation if needed: FORMTEXT      6.FINANCIAL:Sources of income, how this was verified, outline of expense and how expenses were verified, indebtedness, assessment of familys financial stability and ability to meet their needs using their current income. Is the family current on their bills? Can the family meet the financial expenses associated with having a foster child placed in the home prior to any payments starting? FORMTEXT      If child support payments are ordered, are the payments being made and are they current? If there are arrears, how much are they and what is the plan to bring the payments current? FORMTEXT      If income is based on disability, i.e. SSI, Social Security Disability, long term disability payments from a job, workmens compensation, etc., there must be verification of the physical or mental disability and an assessment of how that impacts the ability to provide foster care or be a member of the household.  FORMTEXT      Financial statement completed to reflect debt to income ratio and worker s assessment of financial stability? Yes FORMTEXT      7.SOCIAL HISTORY: (for each adult member of the household)Descriptive information: Age, height, weight, hair color, nationality, race or ethnicity, place of birth. Family of origin description. Includes:Number of siblings, parents roles, personalities, expectations, parenting involvement, styles, values.Relationship with each parent and siblings (if any) growing up and now. Parents/primary caretakers childrearing techniques, including discipline. How family dealt with losses.Parents substance use and how it affected the family, lasting impact on individual if present.How family dealt with any abuse or victimization issues, continuing impact on individual.Role of religion in the family.Other significant relationships, influences, e.g. grandparents, step parents, aunts, uncles.Any history of out of home care? This should include any history in non-court-ordered out of home care.Educational history and any special skills and interest:Employment history If the person does not have an employment history or there are large gaps in the employment history, explain how they were supported during that period of time:Relationship history Significant relationships prior to current one; how they ended; if previously married, whether divorce has been obtained or considered, any children from previous relationships. If there are previous relationships that produced children who are living with the applicant, what is the level of contact with that parent who is not living in the home? Note any history of involvement in domestic violence, including as a victim, or absence of history:Description of personality, personal goals, hobbies, interestStrengths and weaknesses worker s assessment in addition to what they tell you: FORMTEXT      8.HEALTH:Physical, mental and emotional health and substance use history.Indicate current health status:Describe current substance use patterns, history if indicated. If there is a past substance use problem including alcohol use, give particulars, indicate how diagnosed, resolved, and when:Does person smoke?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, do they smoke in the house?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoMental health treatment, if any. Include current prescriptions for psychotropic medications. Documentation from professional providing treatment/medication review:Reference a medical statement, completed within the 12 month period before conclusion of the evaluation, for each member of the household that indicated that the member has no known condition which would affect the care of a foster child or any other determination if different. For non-caregivers, this must include the amount of time it takes for the caregiver to meet the needs of the household member: FORMTEXT      9.FAMILY LIFE:Marital and family status and history, including current and past level of family functioning and relationships and any incidents of domestic violence:Current relationship. Include:Brief history, including date and place of marriage, if applicable.Verification of claimed marriages and divorces.Strengths of relationship, areas of work or attention.Common/shared interests or lack thereof. Roles, division of labor, decision-making process, handling stress or disagreements.Assess stability of the relationship.  FORMTEXT      Family:Activities, goals, values, role of religion, church involvement.  FORMTEXT      Arrangements for substitute childcare and ongoing supervision. FORMTEXT      Challenges, stressors, any history of help-seeking.  FORMTEXT      Losses, including infertility, and how dealt with.  FORMTEXT      Expected impact of fostering on all members of the household. FORMTEXT      Any individuals other than children of applicants living in the family, impact on family.  FORMTEXT      10.CHILDREN:All children must be interviewed/observed apart from the parents, even children no longer living in the home, or the agency must note all attempts to contact them. If unsuccessful, the applicant/other siblings explanations as to why you were unable to contact them. For each child living in the home:Identifiers: name, birth date, race (if different from parents) school and grade, and/or employmentParents description of childs personality, interests, activities.Workers assessment of childs adjustment, development, special needs, relationships with parents and others and strengths and weaknesses. Childs ideas and attitudes about fostering based on interview with the child.Childs description of the discipline techniques used in the family. For children who are grown or out of the home:Identifiers: name, age, where living, marital status. School and/or employment.General adjustment: note if any problems with the law.Their opinion of their parents parenting skills and of their desire to foster children. Description of the discipline techniques used when they were a child. The willingness of the adult child to provide substitute care, if appropriate, or be involved with the foster children who may be placed into the home. 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