Therapeutic Foster Parent Application

Therapeutic Foster Parent Application

(All information is confidential.)

Last Name: ______Date of Application: ______

Home Address: ______

Home Phone: ______Cell Phone: ______

Directions to home: ______

______

County of Residence: ______Inside city limits? Yes ______No ______

Length of Time at Current Address: ______

Date/Place of Marriage (if applicable): ______

Potential Foster Parent #1

Full Name: ______Date of Birth: ______

Last First Middle Maiden

Birthplace: ______Social Security #: ______

Previous married name, if any: ______How terminated?:______

Potential Foster Parent #2

Full Name: ______Date of Birth: ______

Last First Middle Maiden

Birthplace: ______Social Security #: ______
Previous married name, if any: ______How terminated?:______

Education

(Highest Grade Completed)

Parent # 1

Grade School:______

High School:______

Technical College:______

College/University:______

ProfessionalTraining (i.e. Nursing, Teacher’s certificate, etc.):______

Church (if applicable):______

Parent #2

Grade School:______

High School:______

Technical College:______

College/University:______

Professional Training (i.e. Nursing, Teacher’s certificate, etc.):______

Church (if applicable):______

Employment

Parent #1

Employer:______

Address:______

Telephone: (____) ______

Job Title/Position:______

Duration of Employment:______

Work Hours:______

Annual Income:______

Other Training (i.e. CPR, First Aid, TCI, CPI, etc.):

______

Parent #2

Employer:______

Address:______

Telephone: (____) ______

Job Title/Position:______

Duration of Employment:______

Work Hours:______

Annual Income:______

Other Training (i.e. CPR, First Aid, TCI, CPI, etc.):

______

Others living in the home:

NameRelationshipBirth Date Birth Place Education Level

1.______

2.______

3.______

4.______

5.______

Children living out of the home:

NameAge City of ResidenceEducation Level

1.______

2.______

3.______

4.______

5.______

Pets/Animals:______

______

* Are pet(s) shots up to date?Yes______No______

Family Health Problems(Describe):______
Name of Family Physican:______

Residence Information

Is your home a house or an apartment? ______Do you rent or own? ______
How long have you lived at this address?______
Is this home 1-floor/2 floor/split-level/other? (Please describe & indicate # of floors.) ______

Number of rooms:______Number of bedrooms:______Number of bathrooms:______

Do you have a pool?Yes______No______

Please describe the planned sleeping arrangements for foster children:

______

School District:

______

(Grade School) (Middle School) (High School)

Other Information

Foster Child Preferences:Number of Children:______Age:______Gender:______

Have you cared for unrelated children before? (If so, please explain):______

______

Why do you wish to be a foster parent?:______

______

Are there any problems you would prefer not to handle (such as bedwetting, mental retardation, physical handicaps, etc.)? If so, please list:______

______

Has either parent or adult household member ever been…

Investigated for child abuse or neglect?______

______

Arrested or convicted for any charge whatsoever?______

______

Had any involvement with the Juvenile Court regarding your own children?______
______

References

(Non-relatives who have known you for at least three years)

Name Complete Address Telephone

1.______

2.______

3.______

4.______

How did you hear about the Youth Focus Therapeutic Family Services Program?______

______

Have you ever been licensed as a Foster Parent? If yes, where/when?______

______

Are you on any adoption waiting lists?Yes______No______

Registry:______

Additional Comments:______

______

In making my/our application to the Youth Focus Therapeutic Family Services Program, I/We understand there is no commitment by the agency to approve my/our home for the placement of a child(ren). I/We understand that, with my/our permission, the agency will contact employer(s),physicians(s), school personnel, personal references, and law enforcement offices as needed, to collect information related to foster home licensing.
The statements in the application are, to the best of my/our knowledge, true and complete.

Parent Signature:______Date:______

These questions reflect licensing requirements of the state of North Carolina, DHR, DHHS and DSS Children Services.