RCCL does not require that you use this format to complete a foster home screening, and using this format does not guarantee that the screening will meet Minimum Standards.  See Division 2 of Chapter 749, Subchapter M, for all home screening standards.

Prospective Foster Home

Address:
Home Phone:
Directions to Home:

Prospective Foster Parent #1

Name:
Birthdate:
Current Age:
Employer:
Job Title:
Work Phone:
Cell Phone:
Age Verified by:

Prospective Foster Parent #2

Name:
Birthdate:
Current Age:
Employer:
Job Title:
Work Phone:
Cell Phone:
Age Verified by:

Other Household Members (Repeat as Needed)

Name:
Birthdate:
Current Age:
Relationship to Prospective Foster Parents:

 

Interviews

Individual Interview with Prospective Foster Parent #1

Date and method used to contact person
Date of interview
Persons present during interview
Relationship to prospective foster parent of person present during interview
Summary of interview

Individual Interview with Prospective Foster Parent #2 (if applicable)

Date and method used to contact person
Date of interview
Persons present during interview
Relationship to prospective foster parent of person present during interview
Summary of interview

Individual Interview with Child Age 3 and Older Living In the Home #1 (repeat for each child age 3 and older)

Date and method used to arrange interview
Date of interview
Persons present during interview
Relationship to prospective foster parent of person present during interview
Summary of interview

Individual Interview with Household Member #1 (repeat for each household member)

Date and method used to contact person
Date of interview
Persons present during interview
Relationship to prospective foster parent of person present during interview
Summary of interview

Joint Interview with Foster Parents (if applicable)

Date and method used to contact persons
Date of interview
Persons present during interview
Relationship to prospective foster parent of person present during interview
Summary of interview

Family Group Interview (if applicable)

Date and method used to contact persons
Date of interview
Persons present during interview
Relationship to prospective foster parent of person present during interview
Summary of interview

Interview with Adult & minor Children not living in the home (if applicable)

Date and method used to contact person
Date of interview
Persons present during interview
Relationship to prospective foster parent of person present during interview
Summary of interview

Home Visit

Date
Persons Present
Observations made during visit

Attempted Interviews

Document the following for each attempted interview of a person required to be interviewed:

  • Date
  • Person(s) Contacted
  • Relationship of Person(s) to Prospective Foster Parent(s)
  • Method of contact

Prospective Foster Parent Education

Prospective Foster Parent #1 has [select one]
               High school diploma from recognized program
               G.E.D. from recognized program
               Passed the CPA’s screening program

Prospective Foster Parent #2 has [select one]
               High school diploma from recognized program
               G.E.D. from recognized program
               Passed the CPA’s screening program

Personal Characteristics

(Must document that prospective foster parents demonstrate emotional stability, good character, good health, adult responsibility, ability to provide nurturing care, ability to provide appropriate supervision, ability to provide reasonable discipline, and ability to provide a home-like atmosphere for children.)

History of Marital Relationships

(Must document information about any previous marriages, divorces, or deaths of former spouses. Prospective foster parents and caregivers must demonstrate the ability to form and sustain adult relationships.)

History of Residence

Length of time spent at each residence for the past 10 years (street address, city, state)

Citizenship Status

Citizenship of Prospective Foster Parent #1
Citizenship of Prospective Foster Parent #2

Financial Status

(Must verify and document information on the family’s income.  If none, document how this was verified.)

Background Check Results

(Must document results of criminal history and central registry checks for all prospective foster parents and any person, excluding clients, 14 years old or older who will regularly or frequently be staying or present at the home.  You must ask prospective foster parents for information pertaining to any domestic violence calls made regarding their residence in the last 12 months.  You must request background information from the appropriate local law enforcement agencies regarding any domestic violence call disclosed by the prospective foster parents.)

Motivation to Provide Foster Care

(Must assess and document the prospective foster parents’ motivation to provide foster care.)

Health Status of Household Members

(Must document information about the physical and mental health status, including substance abuse history, of all persons living in the home in relation to the family’s ability to provide foster care. You must observe these persons for any indication of problems and follow up, where indicated, with a professional evaluation. Document the information obtained through your observations.)

Quality of Marital and Family Relationships

(Must describe, address, and document the quality of marital and family relationships in relation to the family's ability to provide foster care. Must discuss and assess the stability of a couple's relationship, the strengths and problems of the relationship, and how those issues will relate to foster children placed in the home. Must discuss and assess the quality of the relationships between prospective foster parents and their biological children, living in or out of the home, strengths and problems of those relationships, and how those issues will relate to foster children placed in the home.)

Prospective Foster Parent #1’s Childhood

(Must discuss, assess, and document the prospective foster parent’s feelings about his/her childhood and parents, including any history of abuse or neglect and his/her resolution of those experiences.)

Prospective Foster Parent #2’s Childhood

(Must discuss, assess, and document the prospective foster parent’s feelings about his/her childhood and parents, including any history of abuse or neglect and his/her resolution of those experiences.)

Religion

(Must evaluate and document prospective foster parents on their willingness to respect and encourage a child's religious affiliation (if any), their willingness to provide a child opportunity for religious and spiritual development, if desired, and the health protection they plan to give a child if the foster parents religious beliefs prohibit certain medical treatment.)

Discipline

(Must discuss, assess, and document the prospective foster parents’ knowledge of child development and their child-care experience. Discuss and assess the ways they were disciplined as children and their reactions to the discipline they received. Discuss and assess the prospective foster parents’ discipline styles, techniques, and their ability to recognize and respect differences in children and use discipline methods that suit the individual child. If their current discipline methods are different than those that you approve, discuss and assess how they would change their child-care practices to conform to your approved methods.)

Abused/Neglected Children

(Must discuss, assess, and document the prospective foster parents’ understanding of the dynamics of child abuse and neglect. Discuss and assess their understanding of how these issues and experiences will affect them, their families, and foster children in their care. Discuss and assess the prospective foster parent’s ability to help children who have been abused or neglected. If the prospective foster parent experienced abuse or neglect as a child, assess his/her handling of those experiences and the impact of those experiences on his/her ability to help children deal with their own experiences. Assess the availability of family and community resources to meet the needs of the children in the family’s care.)

Separation and Loss

(Must discuss, assess, and document the prospective foster parents’ understanding of the dynamics of separation and loss and the effects of these experiences on children. Discuss and assess their personal experiences with separation and loss and their processing of those experiences. Assess the potential foster parents’ acceptance of the process of grief and loss for children and assess their ability to help a child through the grieving process.)

Children’s Biological Families

(Must discuss, assess, and document the prospective foster parents’ feelings about the child’s parents, including parents who abused or neglected the child. Discuss and assess their sensitivity and reactions to the biological parents. Discuss and assess their sensitivity to and acceptance of a child’s feelings about his parents and assess their ability to help the child deal with those feelings. Discuss and assess the potential foster parents’ sensitivity to and acceptance of the child’s relationships with his siblings. Discuss and assess their willingness to support the child’s relationships with parents, siblings, and extended family including their support for contacts between the child and his family.)

Household Members’ Perspectives

(Must discuss, assess, and document the attitudes of other household members toward the plan to provide foster care. Discuss and assess their involvement in the care of children, their attitudes toward foster children, and their acceptance of the verification as a foster home.)

Extended Family

(Must discuss, assess, and document the extended family’s attitude toward foster care and foster children and the involvement the extended family will have with foster children. Discuss and assess the impact the extended family’s attitudes will have on the family’s ability to provide foster care and whether the extended family will serve as a support system for the foster family and for foster children.)

Foster Parent Support Systems

(Must discuss, assess, and document the support systems available to the foster family and the support they may receive from these resources.)

Expectations and Plans for Foster Children

(Must discuss, assess, and document the prospective foster parents’ expectations of the child and the flexibility of their expectations in relation to the child’s actual needs and abilities. Discuss and assess their capacities to recognize and emphasize the strengths and achievements of the child and their capacities to adjust their expectations according to the abilities of the child.)

Languages

(Document the language(s) spoken by each prospective foster parent.)

Foster Child Characteristics

(Must discuss, assess, and document the prospective foster family’s ability to work with specific behaviors, backgrounds, special needs and/or disabilities, and other characteristics of foster children.)

Background Information from Other CPAs

Must request and assess the following background information (if provided) from any child-placing agency that previously conducted a foster screening, pre-adoptive home screening, or post placement adoptive report for this family:
(A) The screening, report, home study, and related documentation;
(B) Documentation of supervisory visits and evaluations;
(C) Any record of deficiencies and their resolutions; and
(D) The most current fire and health inspections.

Recommendation

After assessing all available information regarding this prospective foster home, I recommend that the applicant(s) [select one]:

  • NOT be verified as a foster home.
  • Be verified as a foster home caring for [list age range, gender, foster care capacity, and total capacity].
    • This home would work especially well with children who have the following characteristics:
    • This home would need support/assistance working with children who have the following characteristics:
    • This home should NOT work with children who have the following characteristics:

Signed


Child Placement Staff conducting the home screening

Date

Child Placement Management Staff approving the home screening

Date