Questionnaire Form

Have you ever been certified as a foster parent before?

Yes

No

Name of Agency or Facility *

Are you 21 years or older?

Yes

No

What county do you live in?

Are you or the other prospective foster parent employed?

Yes

No

How many bedrooms do you have in your residence?

How many adults and children live in your residence?

If not employed, what is your or the other prospective foster parent’s source of income?

All adults 18 years or older that permanently reside in the home must have fingerprint clearance and a child abuse clearance. Would this be a problem?

Yes

No

Have you or any other adult (18 years or older) that permanently live in the household ever been arrested?

Yes

No

All adults living in the household that are 18 years or older must have a health screening and a TB test. Would this be a problem?

Yes

No

How did you hear about ABC Foster Family Agency?

Name *

Street Address *

City *

State *

Zip *

Telephone Number

When is the best time for an ABC Foster Family Agency employee to reach you?

Have you ever had a referral or contact with Child Protective Services anywhere?

Yes

No

Where

When

Have you ever operated or worked in a daycare facility?

Yes

No

Are you and/or your spouse/partner in good health?

Yes

No

Are you a legal resident of the United States of America?

Yes

No

Have you ever lived in any other state, other than the state of California, within the last five years?

Yes

No

Do you have any pending or unresolved traffic citations (e.g., unpaid traffic tickets)?

Yes

No