County Of Sacramento -Child Protective Services Division
P.O. BOX 269057 * SACRAMENTO, CALIFORNIA 95826-9057
Lynn Frank, DIRECTORLELAND TOM, DEPUTY DIRECTOR
Information about the Birthfather
Date:______Date:
Child’s Name: ______Date of Birth: ______
Birthfather’s Information
Name: ______Other Names Known By: ______
Social Security #:______Driver’s License #:______
Date of Birth:______Birthplace: ______
Current Address:______
Permanent Mailing Address: ______
Current Telephone #:______Permanent Telephone #:______
Paternal Grandparents Information
Grandmother’s Name:______Grandfather’s Name: ______
Address:______Address:______
Address:______Address:______
Telephone #:______Telephone #: ______
Knows About Child’s Placement: Yes No Knows About Child’s Placement: Yes No
Other Relatives
Name:______Relationship:______Contact information:______
Name:______Relationship:______Contact information:______
Name:______Relationship:______Contact information:______
Name:______Relationship:______Contact information:______
Paternity of Child
Have you and the child’s birthmother ever been married? Yes No
If yes, date and place of marriage: ______
If divorced, date and place of divorce: ______
Are you currently married to the birthmother: Yes No
Other Children
Do you have other children? Yes No
If yes, complete the following:
Name / Gender(male or female) / Child’s date
of birth / Person caring for the child (specify relationship to child)
Native American Ancestry
Are you, either of your parents or any other relatives an American Indian? Yes No
If yes, indicate the tribe’s name and location and degree of Indian blood (if known) ______
Psychological Counseling
Have you ever gone to a psychologist, social worker or other counselor for any emotional or psychological problems you may have had? Yes No
If yes, complete the following:
Dates and Reasons for Care:
______
______
Medications prescribed during your care:
______
______
Reason for stopping treatment if no longer under treatment:
______
______
Birthfather’s Education and Occupation
Last Grade Completed: ____Usual Grades in School:______
Occupation:______How long:______
Birthfather’s General Information
Height:____Usual Weight:____Eye Color:______Skin Color:_____Hair Color:_____
Are you right handed or left handed? _____Blood Type:___
Race/Ethnic Group: White Hispanic Filipino Black Asian or Pacific Islander
American Indian or Alaskan Native, Tribe: ______
Other: ______
Specify nationality descent (Example: Irish, French, Mexican, Nigerian, Cantonese, German): ______
Religion: ______
Birthfather’s Personality
Describe your personality in terms of your behavior, attitudes, moods, activities, types of people you enjoy being with, etc.:
______
______
______
Describe talents, hobbies and goals in life: ______
______
______
______
Describe how you were as a child: ______
______
______
Birthfather’s Health History
Describe your general health:______
______
What childhood diseases have you had? Whooping cough Hay fever Ear infection
Rheumatic Fever Scarlet Fever Mumps Roseola Encephalitis
Measles: Rubella (3 days) Heart Murmur Asthma Meningitis Urinary Tract Infection
Measles: Rubeola (2 wks) Chickenpox Other ______
List any major surgeries: ______
______
Are you a twin triplet other multiple birth?
If so, are you an identical or faternal twin
Did you use alcohol, tobacco or other drug substances prior to the child’s conception? Yes_ No
If yes, list what was used, how long and the frequency:______
______
______
Hopes and Dreams for Your Child
Describe your hopes and dreams for your child: ______
______
______
______
______
______
______
Form # (3/07)Distribution: Instructions