home study questionnaire single female

Jonathan’s PlaceFoster/Adopt Care

Child Placing AgencyP.O. Box 140085 Dallas, TX 75246

Phone: (972) 303-1335Fax: (972) 303-5346

ADOPTION OR FOSTER CAREHOMESTUDY

QUESTIONNAIRE Single Female

Latest Revision 06/01/09 of 16 file: CPA Policies/Forms/Single Female Questionnaire

FOSTER / ADOPTIVE HOME STUDY QUESTIONAIRESINGLE FEMALE

HOME NAME:

STREET:

CITY: COUNTY: STATE: ZIP:

PHONE: (Hm) (Wk) (Cell)

HEAD OF HOUSEHOLDName:Age:Date of Birth:Social Security Number:Sex:Ethnicity:Education: Occupation:Employed by:Employer’s Address/Phone:Languages Spoken:Citizenship:Hours of Work:Role in Home:Marital Status:If Married, Date and Place of Marriage:

HOME ANNUAL INCOME:

OTHER HOUSEHOLD MEMBERSName: Name: Name:Age: Age: Age:D.O.B.: D.O.B.: D.O.B.:Sex: Sex: Sex:Ethnicity: Ethnicity: Ethnicity:Education: Education: Education:Occupation: Occupation: Occupation:Role in Home: Role in Home: Role in Home:

Pets: List the names and species of each pet:

Directions to the Home: Provide directions on how to get to your home. Use Jonathan’s Place as a landmark starting point:


I. Applicant’s Feelings About Themselves, Their Parents, and Their ChildhoodThe following questions deal with your interest in and expectations of Adoption or Foster Care.

Mother’s History

Motivation:

What gave you the idea to pursue Adoption or Foster Care at this time?

Have you yourself ever been in Adoption or Foster Care, were you adopted, or do you know anyone who experienced Adoption or Foster Care? If yes, please explain.

If yes, how did your own experience or contact with these people affect your interest in Adoption or Foster Care?

What do you believe to be the major differences between Adoption and Foster Care?

Why are you choosing Foster Care or Adoption?

Please list any agencies which you have previously contacted to become a foster or adoptive parent.

Agency / Location Outcome of contact

Can you think of a situation in which you might later want to adopt a child? (FOSTER CARE ONLY)

Are you physically able to become pregnant?

If yes, are you planning to have any birth children? (FOSTER CARE ONLY)


If no, please explain why you cannot become pregnant.

Description of Applicant: Please provide your height and weight .

How many grades did you complete in school (junior high, high school, college, graduate school)

If you did not complete high school, what were the reasons?

If you have attended college, what were your fields of study and what degrees did you receive?

Since leaving school, please list (from first to current job) places that you have worked:

Job title Length of stay Reason for leaving

Of all the jobs listed above, which did you like best and why?

Of all the jobs listed above, which did you like least and why?

If you are currently employed, please describe your job.


Describe your current duties (what do you do at work).

How long you would like to keep this job and if you are planning to look for another job within the next few years?

Parents:

Mother’s name:

Father’s name:

Describe the quality of you parents’ marital relationship.

Describe your parents’ support and nurturance for each other.

Describe your parents’ support and nurturance for their children.

Describe your parents’ decision making process.

Childhood:

Who were all the members of your family or household (age and relationship) when you were between the ages of:

Birth thru five years old:

Six thru eleven years old:


Twelve thru fifteen years old:

Sixteen until you left home:

Was there anyone not in your household or immediate family with who you were especially close, and why?

Of all the people listed above, to whom were you the closest, and why?

Regarding all the people you listed, where are these people now and how often are you in contact with them?

What ages of your childhood did you most enjoy, and why?

What ages of your childhood did you least enjoy, and why?

With whom did you have the most difficulty getting along, and why?

As you think back over all your school experiences, were they primarily good experiences or bad experiences? Please explain.

When you were growing up, what were “okay” ways for members of your family to express the following feelings?

Happiness:Latest Revision 06/01/09 of 16 file: CPA Policies/Forms/Single Female Questionnaire

Love and affection:

Anger:

Disappointment:

Frustration:

Sadness or depression:

Stress:

Compared to other families you have known, both as a child and as an adult, would you say your family was happier or less happy than most families?

What family traditions that you grew up with do you still keep today, and why?

Are there family traditions, which you grew up with, which you do not keep now, and why?

Think back to the time when you left home to be on your own.

How old were you?

Why did you leave?

How did you and your family feel about your leaving?


What kinds of school experiences did you like the most (example, what subjects? What activities?) Please explain.

What parts of school were the most difficult for you (what classes, what activities?) Please explain.

History of Drug and Alcohol Use:

Did any of your family members when you were growing up abuse drugs or alcohol? If so who are they? What substance did they abuse? What help did they receive, if any?

Do any of your current family members abuse drugs or alcohol or have they abused drugs or alcohol in the past? If so, who are they? What substance (s) did they abuse? Have they received help? If so, from what source did they receive help from?

Do you or any family members use alcohol?

II. Family InteractionThe following questions deal with your previous and current relationships. If you are participating in this application process as a couple, both you and your spouse need to complete this section separately:

Mother’s HistoryPrevious Relationships:

1. If you have been previously married, please list:Latest Revision 06/01/09 of 16 file: CPA Policies/Forms/Single Female Questionnaire

Marriage 1 Marriage 2 (List others on addn’l page)

Name of spouse:

Date of marriage:

Place of marriage:

Reason for Termination:(e.g., divorce, death)

Date of Termination:

2. Please list any children you have from previous marriages or relationships that do not currently live with you.

Name Age Where they live and with whom

What contact do you have with the persons listed in Questions 1 and 2?

How did you deal with your angry and sad feelings about the ending of your marriage?

If you have remarried or entered into a new relationship with someone other than your children’s father, how did your children adjust to the new person?

Mother’s History:How are decisions made in your family?

What issues usually cause the most arguments, and how are the arguments ended?

How are the chores in your family divided up? What happens when someone doesn’t want to do his or her chores?


Parenting: The following questions deal with your parenting. If you are participating in this application process as a couple, both you and your spouse need to complete this section separately:

Mother:As you think about becoming a foster parent or adoptive parent:

What do you think you will like most?

What do you think you will like least?

If you have any children who do not live with you, please list:Name Age Where/ with whom they live Relationship Amt of Time

(birth child, step child) Spent w/them

How do the persons listed above feel about your becoming a foster or adoptive parent?

What have you enjoyed most about parenting?

What have you disliked most about parenting?

What childhood ages do you most enjoy parenting?

What childhood ages do you least enjoy parenting?Latest Revision 06/01/09 of 16 file: CPA Policies/Forms/Single Female Questionnaire

What forms of discipline do you find to be most effective?

Under what circumstances do you think it is okay to spank, smack, or hit a child?

Have you ever been a parent to someone else’s child? If yes, please describe the circumstances.

Single Parent:How long have you been a single parent, and what were the circumstances that caused you to be a single parent?

How do you think becoming a foster or adoptive family will affect the following situations?

The amount of free time you have?

The amount of time you have with the children already in your home?

The way chores are divided up in your family?


The way you express feelings of happiness, anger, disappointment, frustration, stress, sadness, depression?

What do you imagine will be the most positive impact of fostering or adopting on your family?

What do you think will be the least positive or the most difficult part of the fostering or adopting?

To whom do you go for help when you are feeling lonely or worried?

How does this person (or do these persons) feel about your becoming a foster or adoptive parent?

There are several activities that we need you to complete and attach to this section:

Please give us a picture of you and all the members of your household (including pets, if possible) standing in front of your house.

Please write a brief letter to a child who might be coming to live with you, telling the child some of the things you think he or she might want to know about you, your family, and your home.

(The picture and letter will be used by the social worker who places a child in your home to help the child get prepared for your family.)

Please also write a brief letter or note to the parents of a child whom may be placed with you. In this note, please briefly tell the parents some things about yourself that would reassure them about your ability to foster their child.

Other Household Members: Who are all the members of your current family/household? (Please list full name, age, relationship-starting with the oldest adult through the youngest child.)


Religion: Do you belong to a place of worship, and would it be important to you that a child placed with you share the same religious beliefs and background?

Family Rules and Boundaries: Every family has rules (for example: no swearing, no walking around the house barefoot). Regarding the rules in your home:

What rules can sometimes be broken?

What rules can never be broken?

How do you handle privacy and nudity in your home?

How Family Members Handle Stress and Express Negative Feelings:

In your current family, what are “okay” ways for members to express the following feelings?

Happiness

Love/affection

Anger

Disappointment

Frustration


Sadness/depression

Stress

Extended Family: What do you think others in your family will like best and least about having a new child in your home?

III. Home Environment (The applicant’s home and neighborhood)

Imagine that we are going to describe your home and neighborhood to a child that we are going to place with you, or to the parents of that child. How would you like for us to describe your home and community?

How would you describe your relationship with your neighbors?

How do your neighbors feel about your becoming a foster or adoptive family?

Who are the people who most regularly visit your home, or whose homes you regularly visit?

How do these people feel about your becoming a foster or adoptive family?

Type of home: (check one)

ApartmentDuplexSingle-family houseMobile homeOther

How long have you lived here?


List all other residences (addresses) where you have lived for the past 10 years.

MotherResidence Years lived there

Please attach a floor plan of your home and indicate the room where a new child would sleep. Please indicate the number of feet along the dimensions of length and the width of each room.

Describe any pets that you have. Please give the type of pet, name, and how long the pet has been in your family.

If a child with you was afraid of your pet, or became allergic to the pet, what would you do?

What are the ways in which a new child placed in your home might cause some problemsor concerns in the maintenance of your home and housekeeping standards?

What form of transportation do you use to get the following places?

Grocery store:Doctor’s office:Hospital:Department store:Place of worship:

If you were in a financial crisis (financial, emotional, medical, etc.), to whom would you go for help?


Safety issues:

Is your house free of lead paint?

Where are smoke alarms located?

Do you have private well water? If yes, how often is it tested?

Child Management and Discipline:How important will grades and school performance be for the child placed in your home?

What are your school expectations for a child placed in your home?

Type of Child:Imagine that today is the day you are going to meet the child who will be placed in your home. Please describe this child age, sex, personality, appearance, family background.


home study questionnaire single female

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