Number of Children Sex of Child Age of Child Race of Child

COMFORT ZONES FORM

Foster Family Name: Date:

Please check the type of children you feel comfortable working with. Please check as many as apply within each category.

Number of Children Sex of Child Age of Child Race of Child

___One Child ___ Male ___ 0-2 years ___ White

___Two Children ___ Female ___ 3-5 years ___ African American

___Three Children ___ 6-9 years ___ Biracial

___Four Children ___ 10-12 years ___ Hispanic

___Five Children ___ 13-15 years ___ Asian

___Other______16-18 years ___ American Indian

___ Any Race

Intellectual Functioning Physical Characteristics Emotional Functioning

___ Above Average ___ No Physical Impairment ___ No Emotional Problems

___ Average ___ Moderate Impairment ___ Moderate Problems

___ Slow Learner/Borderline ___ Severe Impairment ___ Severe Problems

___ Moderate/Mental Retardation

___ Severe Mental Retardation

Please mark the characteristics/behaviors you feel you could handle in your home.

___ Tantrums ___ Lying ___ Manipulating

___ Aggression ___ Profanity ___ Independent

___ Self-destructive behavior ___ Talking back ___ Outbursts

___ Hurts animals ___ Argumentative ___ Rude

___ Stealing ___ Withdrawn ___ Runaway (history of)

___ Truancy ___ Poor self-image ___ Hoards food

___ Problems at school ___ Seductive ___ Poor appetite

___ Victim of sexual abuse ___ Sexual perpetrator ___ Sexually active

___ Bedwetting ___ Stool smearing ___ Sexually acts out

___ Smokes cigarettes ___ Uses drugs ___ Poor hygiene

___ Exposed to violence ___ Oppositional defiant ___ Plays with matches

___ Depression ___ Bipolar ___ Attachment disorder

___ Destructive to objects ___ Defiant ___ ADHD

Are you willing to work with a child who: (please mark all that apply)

___ Has weekly therapy ___ Has a lot of transportation needs

___ Takes medication ___ Displays bizarre behaviors

___ Has been charged with a crime ___ Has a lot of appointments

___ Parent has been in a mental institution ___ Parent has been diagnosed with a mental illness

___ Relative has been in a mental institution ___ Relative has been diagnosed with a mental illness

Additional Characteristics or Considerations: