Adoption & Foster Care

First Name:

Last Name:

First Name:

Last Name:

Email:

Address:

Address Line 2:

City:

State:

Zip Code:

1. What is your relationship with the applicant(s):

a. How long have you known each of them?:

b. How often do you interact (face to face) with them?:

2. List any qualities the applicants have that would be helpful and/or benefit them as parents:

3. Have you witnessed the applicant(s) interaction with children and how would you describe them?

4. If applicable, what methods of discipline do they use with their own children and does it appear to be effective?

5. Describe the applicant(s) relationship with their families (immediate and extended).

6. Do you have any additional comments and/or concerns about the applicant(s) ability to be a foster or adoptive parent? If yes, please eplain further.

With 1 being the lowest and 5 being the highest, please rate the following areas re: applicant(s):

• Home/environment is suitable for parenting a child of any race or ethnicity (consider extended family, community & school): 12345

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Resource Family Reference Questionnaire:

Resource Parent Applicant:

Reference:

Questionaire: