Kinship Caregiver Demographics (Child)

Caregiver's Name

First NameLast Name

1. Please provide information on the kinship child(ren) (under 18) currently living in your home

First NameMiddle NameLast Name

2. Gender

MaleFemale2-SpiritedOther

3. Birthdate

Date

4. Race/Ethnicity (check all that apply)

Tribal Affiliation if applicable

5. Time Kinship child has been in your care:

6. Have you been caring for the kinship child continuously?

YesNoIntermittently

7. What is your relationship to the kinship child?

8. Relationship of the kinship child to other children in the home

9. Please indicate the reason(s) your kinship child came to be in your care: (select all that apply)

10. Please select the option that best describes your role:

Informal *Defined as kinship care provided without involvement with CYFD/CPS or formal child welfare system *if selected, proceed to question 11. Do not answer questions 12 & 13.Formal *To be a formal kinship provider, your kinship child had to be placed in your home because of a CYFD/CPS investigation or involvement with the child welfare system. *If selected, answer questions 12 & 13.

11. If you are caring for your kinship child through an informal arrangement, please indicate if any of these arrangements apply to your situation. (check all that apply)

12. If your kinship child was placed in your home with the involvement of Child Welfare (Tribal or otherwise) and the court, did you choose to be licensed? (Please answer yes if you were a licensed foster parent before the child’s placement)

NoYesIf yes, name of Child Welfare agency:

13. Please identify if you have completed one of these permanent plans for your kinship child.

Adoption (includes customary adoption)GuardianshipNon-parental custody (sometimes referred to as third-party custody)Other, please specify

Kinship Caregiver Demographics Child