Foster Parent Application
All information is Strictly Confidential
Applicant One
Choose one applicant to complete this section
Name
First Name
Middle Name
Last Name
Maiden Name
Gender
Date of Birth
Place of Birth
Social Security Number
Religion
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Military Experience
Branch
Length of Service
Type of Discharge
Education
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FOSTER PARENT APPLICATION
Coastal Behavior Health Services, Inc.
All Information Is Strictly Confidential
APPLICANT ONE: Choose one applicant to complete this section.
Name
First Name
Middle Initial
Last Name
Maiden Name
Gender
Date of Birth
-
Month
-
Day
Year
Date
Place of Birth
Social Security Number
Religion
Phone Number
Format: (000) 000-0000.
MILITARY EXPERIANCE
Branch
Length of Service
Type of Discharge
EDUCATION
Grammar I Institution
Year Attended
High School I Institution
Year Attended
Degree
College I Institution
Year Attended
Degree
College I Institution
Year Attended
Degree
EMPLOYMENT
Present Employer | Company Name
Start Date
-
Month
-
Day
Year
Date
PT or FT
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Job Title
Gross Salary
Phone Number
Format: (000) 000-0000.
Previous Employer | Company Name
Start Date
-
Month
-
Day
Year
Date
End Date
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Job Title
Phone Number
Format: (000) 000-0000.
Previous Employer | Company Name
Start Date
-
Month
-
Day
Year
Date
End Date
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Job Title
Phone Number
Format: (000) 000-0000.
Previous Employer | Company Name
Start Date
-
Month
-
Day
Year
Date
End Date
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Job Title
Phone Number
Format: (000) 000-0000.
FAMILY
Father I Name
Age
Occupation
Health
Address
Page 1 of 21
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Mother I Name
First Name
Last Name
Age
Occupation
Health
Address
Sibling I Name
First Name
Last Name
Age
Occupation
Health
Address
Sibling I Name
First Name
Last Name
Age
Occupation
Health
Address
Sibling I Name
First Name
Last Name
Age
Occupation
Health
Address
Sibling I Name
First Name
Last Name
Age
Occupation
Health
Address
Sibling I Name
First Name
Last Name
Age
Occupation
Health
Address
CRIMINAL HISTORY
Have you ever been arrested as a juvenile?
Yes
No
Have you ever been arrested as a adult?
Yes
No
Have you ever received psychological psychiatric treatment?
Yes
No
Have you ever been studied for foster care or adoption?
Yes
No
If there is a YES answer to any of the above four questions, please explain circumstances please attach a separate sheet if needed.
NOTE: to be approved as an Adoptive or Foster parent, you must authorize a search of police records to verify that you have no record which would make you unsuitable to be adoptive/foster parents. You may be approved if the social worker feels that you have made a satisfactory adjustment since the arrest(s) or convictions.
For persons convicted of crimes against children such as neglect, abuse or sexual exploitation, the application shall be denied.
FIVE REFERENCES
Please provide names of ten (10) persons who know you both. Preferred references are persons living in the same community as applicants.
REFERENCE ONE I Name
First Name
Last Name
Phone Number
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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REFERENCE TWO
First Name
Last Name
Phone Number
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
REFERENCE THREE
First Name
Last Name
Phone Number
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
REFERENCE FOUR
First Name
Last Name
Phone Number
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
REFERENCE FIVE
First Name
Last Name
Phone Number
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
APPLICANT TWO: Choose one applicant to complete this section.
Name
First Name
Middle Initial
Last Name
Maiden Name
Gender
Date of Birth
-
Month
-
Day
Year
Date
Place of Birth
Social Security Number
Religion
Phone Number
Format: (000) 000-0000.
MILITARY EXPERIANCE
Branch
Length of Service
Type of Discharge
EDUCATION
Grammar I Institution
Year Attended
High School I Institution
Year Attended
Degree
Year Attended
Degree
I Institution
Year Attended
Degree
I Institution
EMPLOYMENT
Present Employer I Company Name
Start Date
-
Month
-
Day
Year
Date
PT or FT
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Job Title
Gross Salary
Phone Number
Format: (000) 000-0000.
Previous Employer I Company Name
Start Date
-
Month
-
Day
Year
Date
End Date
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Job Title
Phone Number
Format: (000) 000-0000.
Previous Employer I Company Name
Start Date
-
Month
-
Day
Year
Date
End Date
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Job Title
Phone Number
Format: (000) 000-0000.
Previous Employer I Company Name
Start Date
-
Month
-
Day
Year
Date
End Date
-
Month
-
Day
Year
Date
Page 3 of 21
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Address
City
State
Zipcode
Job Title
Phone Number
Format: (000) 000-0000.
FAMILY
Father I Name
Age
Occupation
Health
Address
Mother I Name
Age
Occupation
Health
Address
Sibling I Name
Age
Occupation
Health
Address
Sibling I Name
Age
Occupation
Health
Address
Sibling I Name
Age
Occupation
Health
Address
Sibling I Name
Age
Occupation
Health
Address
Sibling I Name
Age
Occupation
Health
Address
CRIMINAL HISTORY
Have you ever been arrested as a juvenile?
Yes
No
Have you ever been arrested as a adult?
Yes
No
Have you ever received psychological psychiatric treatment?
Yes
No
Have you ever been studied for foster care or adoption?
Yes
No
If there is a YES answer to any of the above four questions, please explain circumstances please attach a separate sheet if needed.
NOTE: to be approved as an Adoptive or Foster parent, you must authorize a search of police records to verify that you have no record which would make you unsuitable to be adoptive/foster parents. You may be approved if the social worker feels that you have made a satisfactory adjustment since the arrest(s) or convictions.
For persons convicted of crimes against children such as neglect, abuse or sexual exploitation, the application shall be denied.
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FIVE REFERENCES
Please provide names of ten (10) persons who know you both. Preferred references are persons living in the same community as
applicants.
REFERENCE ONE I Name
First Name
Last Name
Phone Number
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
REFERENCE TWO I Name
First Name
Last Name
Phone Number
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
REFERENCE THREE I Name
First Name
Last Name
Phone Number
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
REFERENCE FOUR I Name
First Name
Last Name
Phone Number
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
REFERENCE FIVE I Name
First Name
Last Name
Phone Number
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
APPLICANT ONE & TWO: Both applicants complete this section. When asked, use your chosen applicant number to answer sections.
MARRIAGE HISTORY
Present Marriage I Date of Marriage
-
Month
-
Day
Year
Date
Where did you get married? Placed - Town, Country & State
Applicant One Previous Marriages
Name
Date and Place of Marriage
-
Month
-
Day
Year
Date
Date and Place of Divorce
-
Month
-
Day
Year
Date
Date of Spouse Death
-
Month
-
Day
Year
Date
Name
Date and Place of Marriage
-
Month
-
Day
Year
Date
Date and Place of Divorce
-
Month
-
Day
Year
Date
Date of Spouse Death
-
Month
-
Day
Year
Date
Applicant Two Previous Marriages
Name
Date and Place of Marriage
-
Month
-
Day
Year
Date
Date and Place of Divorce
-
Month
-
Day
Year
Date
Date of Spouse Death
-
Month
-
Day
Year
Date
Name
Date and Place of Marriage
-
Month
-
Day
Year
Date
Date and Place of Divorce
-
Month
-
Day
Year
Date
Date of Spouse Death
-
Month
-
Day
Year
Date
CHILDREN IN THE HOME
Child One I Name
Birth Date
-
Month
-
Day
Year
Date
SSN
Occupation or School Grade
Birth
Adopted
Child One I Name
Birth Date
-
Month
-
Day
Year
Date
SSN
Occupation or School Grade
Birth
Adopted
Page 5 of 21
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Child Three I Name
First Name
Last Name
Birth Date
-
Month
-
Day
Year
Date
SSN
Occupation or School Grade
Birth
Adopted
Child Four I Name
First Name
Last Name
Birth Date
-
Month
-
Day
Year
Date
SSN
Occupation or School Grade
Birth
Adopted
CHILDREN OUT OF THE HOME
Child One I Name
First Name
Last Name
Birth Date
-
Month
-
Day
Year
Date
Birth
Adopted
Occupation or School Grade
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child Two I Name
First Name
Last Name
Birth Date
-
Month
-
Day
Year
Date
Birth
Adopted
Occupation or School Grade
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child Three I Name
First Name
Last Name
Birth Date
-
Month
-
Day
Year
Date
Birth
Adopted
Occupation or School Grade
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child Four I Name
First Name
Last Name
Birth Date
-
Month
-
Day
Year
Date
Birth
Adopted
Occupation or School Grade
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
CHILDREN DECEASED
Child One I Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Child Two I Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
OTHERS LIVING IN THE HOME - ADULTS AND CHILDREN
Name
First Name
Last Name
Birth Date
-
Month
-
Day
Year
Date
SSN
Occupation or School Grade
Relationship
Name
First Name
Last Name
Birth Date
-
Month
-
Day
Year
Date
SSN
Occupation or School Grade
Relationship
Name
First Name
Last Name
Birth Date
-
Month
-
Day
Year
Date
SSN
Occupation or School Grade
Relationship
IF ADDITIONAL ROOM IS NEEDED TO LIST FAMILY MEMBERS, USE THE EXTRA PAGES ATTACHED.
INSURANCE COVERAGE
Automobile
Life
Hospital
Other Insurance
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Other Assets
HOME INFORMATION
Current Residence
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Number of Bedroooms
Mortgage Per Month
Rent Per Month
House
Apartment
Mobile Home
How long have you lived at your current address
months
Directions to finding home
Mailing Address - If different from current address
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Applicant One Previous Address - For the last 5 years
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dates I From
-
Month
-
Day
Year
Date
To
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dates I From
-
Month
-
Day
Year
Date
To
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dates I From
-
Month
-
Day
Year
Date
To
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dates I From
-
Month
-
Day
Year
Date
To
-
Month
-
Day
Year
Date
Applicant Two Previous Address - For the last 5 years
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dates I From
-
Month
-
Day
Year
Date
To
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dates I From
-
Month
-
Day
Year
Date
To
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dates I From
-
Month
-
Day
Year
Date
To
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dates I From
-
Month
-
Day
Year
Date
To
-
Month
-
Day
Year
Date
IF ADDITIONAL ROOM IS NEEDED TO LIST FAMILY MEMBERS, USE THE EXTRA PAGES ATTACHED.
Primary Language Spoken in the Home
Other Languages Spoken in the Home
Applicant One Religion
Applicant Two Religion
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APPLICANT ONE & TWO: Both applicants complete this section. When asked, use your chosen applicant number to answer sections.
Your Family Background
Tell us about the people who raised you. Who were they and did you get along with them? Applicant One
Applicant Two
How did you get along with your brothers and sisters when you were growing up? Applicant One
Applicant Two
Which of your family members are you still close to? How often do you see or speak with them? Applicant One
Applicant Two
Has any member of your family ever been arrested or charged with a violation of the law? Applicant One
Yes
No
If yes, please explain
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Applicant Two
Yes
No
Has any member of your family and/or household ever been in foster care?
Applicant One
Yes
No
Applicant Two
Yes
No
Your Childhood
As you were growing up, which family members were you closest to? Why? What made them special to you?
Applicant One
Applicant Two
What was the hardest part of growing up for you?
Applicant One
Applicant Two
What was the best part of growing up for you?
Applicant One
Page 9 of 21
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Applicant Two
What were you usually punished for?
Applicant One
Applicant Two
How were you punished? By Whom?
Applicant One
Applicant Two
Your Education
How did you feel about school?
Applicant One
Applicant Two
What do you remember the most about school?
Applicant One
Page 10 of 21
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Applicant Two
Your Marriage/Relationship
List three things you like most about your present marriage relationship?
Applicant One
Applicant Two
What do you most admire about your spouse/partner?
Applicant One
Applicant Two
What crisis have you dealt with together and how was it handled?
Applicant One
Applicant Two
What would make your marriage/relationship better?
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Applicant Two
Previous Marriages
If this (these) marriages(s) ended in divorce, what was the reason for the divorce(s)? Applicant One
Applicant Two
Have you ever been married before? Applicant One
Yes
No
If yes, how many times?
Applicant Two
Yes
No
If yes, how many times?
If this (these) marriages(s) ended in divorce, what was the reason for the divorce(s)? Applicant One
Applicant Two
How is your present marriage/relationship different? Applicant One
Applicant Two
Do you have children from other than your current marriage/relationship?
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Applicant One
Yes
No
Name of child
Birth date
Where do they live know?
Applicant Two
Yes
No
Name of child
Birth date
Where do they live know?
If these children are not living with you, in what ways do you keep in touch and provide support? Applicant One
Applicant Two
FOR SINGLE APPLICANT: To be completed by single-parent households only.
Please describe your dating patterns for the last six (6) months Applicant One
What role will this person have with children placed with you? Applicant One
How old were you when you had your first child? Applicant One
What three (3) things do you like most about being a parent?
Page 13 of 21
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Applicant One
What is special about each of your children?
What do your children do that upsets you the most?
What do you do when you are upset with your children?
How do you discipline your children? What methods are most effective?
What advice would you give to a person thinking about having their first child?
What advice would you give to a person thinking about having their first child?
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Applicant One
APPLICANT ONE & TWO: Both applicants complete this section. When asked, use your chosen applicant number to answer sections.
Your Role as an Foster/Adoptive Parent
Why do you want to foster/adopt a child? Applicant One
Applicant Two
What do you think will be the best part about being a foster/adoptive parent? Applicant One
Applicant Two
What do you think will be the hardest part about being a foster/adoptive parent? Applicant One
Applicant Two
Please tell us about the people who will help you out when you need child care, advice, etc? Applicant One
Page 15 of 21
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Applicant Two
How will the placement of a child affect your relationship to other immediate and extended family members?
Applicant One
Applicant Two
How would you handle visits between the children and their parents?
Applicant One
Applicant Two
If you are now (or have ever) parented a child that was not your birth child, what was the relationship (for example, step child, relative, friend) and how long did you parent this child?
Applicant One
Applicant Two
In what ways was it different?
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Applicant One
Are you willing to accept a child with the following?
Rows
NO
YES
Column 3
MILD
MODERATE
SEVERE
1
2
3
4
Medical History
Are you currently under the care of any doctor? Explain:
Applicant Two
What medications do you use regularly? Explain:
Applicant Two
Do you have any chronic or recurring physical ailments (such as migraine, backaches, or arthritis)? Explain
Applicant Two
Page 17 of 21
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Please list any injuries, illnesses or operations you have had as an adult which required hospitalization?
Applicant One
Applicant Two
Your Household
Has any member of your household ever had a drug or alcohol related problem
Applicant One
Yes
No
If yes, please explain
Applicant Two
Yes
No
If yes, please explain
How does each member of your family show love and affection?
Applicant One
Applicant Two
When someone in the family is sad or upset, what do the other family members do to help?
Applicant One
Applicant Two
Page 18 of 21
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When your family has to make a decision, who participates and how do you arrive at a decision?
Applicant One
Applicant Two
How do you resolve or settle disagreements?
Applicant One
Applicant Two
What usually makes each members of your family angry?
Applicant One
Applicant Two
How does each of your family members act when they are angry?
Applicant One
Applicant Two
Page 19 of 21
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Children
What adjustments would you have to make if a child coming into your home has a religious preference other than yours?
Applicant One
Applicant Two
What kinds of recreational activities does your family participate in?
In which, if any, community activities are members of your family involved? (For example, schools, volunteer
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ACKNOWLEDGMENT AND SIGNATURE: In signing this form, prospective foster parents are verifying that they have received a copy of and are acknowledging the following conditions of licensure/approval and that the information provided on this application is a truthful representation.
The persons given as references will be contacted by mail, telephone or in a home visit.
Police reports and FBI fingerprints will be checked and verified.
Military history, employment, marriage and divorces will be verified.
Medical records of the applicants will be requested and reviewed.
Pre-service training is mandatory for both applicants (and those household members over age 18)
Foster parents agree to adhere to the laws and regulations applying to foster children.
No independent planning, including adoption planning, for foster children shall be made by the applicant(s).
An application for foster care does NOT guarantee a license. Approval for placement of a child. An approval or denial is based on the suitability of the family for children.
I (WE) UNDERSTAND THAT SIGNING THIS APPLICATION DOES NOT GUARANTEE THAT A FOSTER HOME LICENSE WILL BE ISSUED TO ME (US). THIS APPLICATION IS THE BEGINNING STEP IN COMPLETION THE HOME STUDY PROCESS.
If my (our) application is approved, I (we) am (are) NOT guaranteed placement in my (our) home.
First Applicant Signature
Date
-
Month
-
Day
Year
Date
Second Applicant Signature
Date
-
Month
-
Day
Year
Date
Page 21 of 21
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