Therapeutic Foster Care Parent Application

Today's Date*

MM

DD

YYYY

Name of Prospective Mother*

Age*

Name of Prospective Father*

Age*

Length of Marriage*

If Applicable

Address*

Street Address City State ZIP Code

Cell Phone: Mother*

Cell Phone: Father*

Home Phone*

Work Phone*

Email*

Children in the Home*

Please list all children's names and ages.

Name of Child	Age

Interested in Fostering:*

Age(s)	Gender	Ethnicity

About Perspective Parents & Home

Are both prospective parents employed?*

Yes
No

Name of Employer*

Length of Employment*

Employer Phone*

Name of Second Parent's Employer*

Length of Second Parent's Employment*

Second Parent's Employer Phone*

What prompted your interest in becoming a Therapeutic Foster Care Parent?*

Is your home in good repair?*

Is your home kept clean?*

How many bedrooms and people per bedroom are currently in your home?*

How many bathrooms are in your home?*

How many people are currently living in your home?*

Please list the age and gender of each person living in your home.

Age	Gender

Additional Information:

Please add other important information not already mentioned.

Strengths & Needs Checklist

Do you have current certifications in CPR and First-Aid?*

Yes
No

Are you willing to take classes to be certified in Adult/Child CPR and basic first-aid?*

Yes
No

Is there adequate bedroom space for the child and those that are currently residing in the home?*

Yes
No

Is there adequate drawer and closet space in the bedrooms?*

Yes
No

Is there adequate play space (inside and outside)?*

Yes
No

Is there adequate living space for all family members?*

Yes
No

Are firearms kept unloaded and locked away?*

Yes
No
N/A

Is ammunition stored separately and locked way?*

Yes
No
N/A

Are harmful substances such as ammonia based household cleaning products stored appropriately?*

Yes
No

Are necessary safety precautions taken regarding swimming pools, trampolines, weight lifting equipment, four wheelers, etc.?*

Yes
No
N/A

Are there working smoke detectors near each bedroom?*

Yes
No

Is there a fire extinguisher in the kitchen?*

Yes
No

Are all medications locked away or out of reach?*

Yes
No

Do you have adequate first-aid supplies?*

Yes
No

Are safety drills conducted monthly?*

Yes
No

Will the child have adequate care during the summer?*

i.e. taken to day care, transported to a summer camp, or remain in the home

Yes
No

Can you commit to completing the necessary paperwork?*

Yes
No

Can you commit to a meeting with the program manager once a week or at least every other week?*

Yes
No

Can you attend a service team meeting once a month for each child in your home?*

Yes
No

Can you transport the child when necessary to appointments, school, service team meetings, or therapy sessions?*

Yes
No

Will you be able to respect the cultural, ethnic, and religious differences of the child?*

Yes
No

Will you collaborate with teachers, biological parents, and service team members as needed?*

Yes
No

Can you commit to 24 hours yearly of additional training?*

Yes
No

Can you say that money will not be the major factor in the decision to become a Therapeutic Foster Care Parent?*

Yes
No

Will you accept a child that may have severe behavioral or emotional problems?*

Yes
No

Can you commit to having a list of rules and consequences that everyone must follow regardless if the child is biological or fostered?*

Yes
No