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