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Home Study Questionnaire Joint
 

Home Study Questionnaire Joint

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Please complete IF you are a two-parent foster/adopt household.

Please complete IF you are a two-parent foster/adopt household.

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    Home Study Questionnaire Joint Home Study Questionnaire Joint Document Transcript

    • Jonathan’s Place Foster/Adopt Care Child Placing Agency P.O. Box 140085 Dallas, TX 75246 Phone: (972) 303-1335 Fax: (972) 303-5346 ADOPTION OR FOSTER CARE HOMESTUDY QUESTIONNAIRE Joint Latest Revision 06/01/09 Page 1 of 31 file: CPA Policies/Forms/Joint Questionnaire
    • FOSTER / ADOPTIVE HOME STUDY QUESTIONNAIRE JOINT HOME NAME: STREET: CITY: COUNTY: STATE: ZIP: PHONE: (Hm) (Wk) (Cell) HEAD OF HOUSEHOLD Name: Name: Age: Age: Date of Birth: Date of Birth: Social Security Number: Social Security Number: Sex: Sex: Ethnicity: Ethnicity: Education: Education: Occupation: Occupation: Employed by: Employed by: Employer’s Address/Phone: Employer’s Address/Phone: Languages Spoken: Languages Spoken: Citizenship: Citizenship: Hours of Work: Hours of Work: Role in Home: Role in Home: Marital Status: Marital Status: If Married, Date and Place of Marriage: HOME ANNUAL INCOME: OTHER HOUSEHOLD MEMBERS Name: 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: Latest Revision 06/01/09 Page 2 of 31 file: CPA Policies/Forms/Joint Questionnaire
    • I. Applicant’s Feelings About Themselves, Their Parents, and Their Childhood The following questions deal with your interest in and expectations of Adoption or Foster Care. If you are participating in this application process as a couple both you and your spouse need to complete 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) Latest Revision 06/01/09 Page 3 of 31 file: CPA Policies/Forms/Joint Questionnaire
    • 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: (Mother) 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? Latest Revision 06/01/09 Page 4 of 31 file: CPA Policies/Forms/Joint Questionnaire
    • 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. Latest Revision 06/01/09 Page 5 of 31 file: CPA Policies/Forms/Joint Questionnaire
    • 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? Latest Revision 06/01/09 Page 6 of 31 file: CPA Policies/Forms/Joint Questionnaire
    • 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: • Love and affection: • Anger: • Disappointment: • Frustration: • Sadness or depression: • Stress: Latest Revision 06/01/09 Page 7 of 31 file: CPA Policies/Forms/Joint Questionnaire
    • 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. Latest Revision 06/01/09 Page 8 of 31 file: CPA Policies/Forms/Joint Questionnaire
    • 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? Family Interaction The 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 History Previous Relationships: 1. If you have been previously married, please list: 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: Latest Revision 06/01/09 Page 9 of 31 file: CPA Policies/Forms/Joint Questionnaire
    • 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: Current Relationships: How did you meet your spouse? How long have you: Known each other Been married Been living together What do you think was the main reason you married this person and the main reason why you have stayed together? Latest Revision 06/01/09 Page 10 of 31 file: CPA Policies/Forms/Joint Questionnaire
    • What do you most admire about your spouse and what do you think your spouse admires most about you? What would you most like to change about your spouse and what do you think he or she would like to have you change? What do you most like about being married? What do you like least about being married? What circumstances would make you want to consider divorce? How much time during the week do you and your spouse have alone together, and do you feel comfortable with this amount of time? 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, and what happens when someone doesn’t want to do his or her chores? Latest Revision 06/01/09 Page 11 of 31 file: CPA Policies/Forms/Joint Questionnaire
    • How do you think becoming a foster or adoptive family will affect the following situations? The amount of time you and your spouse have alone together: The amount of time you have with the children already in your home? The way chores are divided up in your family: The way your family expresses happiness, love, affection, anger, disappointment, stress, frustration, sadness: What do you imagine will be the most positive impact of adoption or foster care on your family? What parts of adoption or foster care do you think might cause you the most difficulty? 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? Latest Revision 06/01/09 Page 12 of 31 file: CPA Policies/Forms/Joint Questionnaire
    • 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 Page 13 of 31 file: CPA Policies/Forms/Joint 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. II. Applicant’s Feelings About Themselves, Their Parents, and Their Childhood The following questions deal with your interest in and expectations of Adoption or Foster Care. If you are participating in this application process as a couple both you and your spouse need to complete this section separately: Father’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? Latest Revision 06/01/09 Page 14 of 31 file: CPA Policies/Forms/Joint Questionnaire
    • 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 father a child? If yes, are you planning to have any birth children? (FOSTER CARE ONLY) If no, please explain why you cannot father a child. Latest Revision 06/01/09 Page 15 of 31 file: CPA Policies/Forms/Joint Questionnaire
    • Description of Applicant: (Father) 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? Latest Revision 06/01/09 Page 16 of 31 file: CPA Policies/Forms/Joint Questionnaire
    • 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. Latest Revision 06/01/09 Page 17 of 31 file: CPA Policies/Forms/Joint Questionnaire
    • 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? Latest Revision 06/01/09 Page 18 of 31 file: CPA Policies/Forms/Joint Questionnaire
    • 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: • Love and affection: • Anger: • Disappointment: • Frustration: • Sadness or depression: • Stress: Latest Revision 06/01/09 Page 19 of 31 file: CPA Policies/Forms/Joint Questionnaire
    • 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. Latest Revision 06/01/09 Page 20 of 31 file: CPA Policies/Forms/Joint Questionnaire
    • 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? Family Interaction The 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: Father’s History Previous Relationships: 1. If you have been previously married, please list: 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: Latest Revision 06/01/09 Page 21 of 31 file: CPA Policies/Forms/Joint Questionnaire
    • 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 mother, how did your children adjust to the new person? Father’s History: Current Relationships: How did you meet your spouse? How long have you: Known each other Been married Been living together Latest Revision 06/01/09 Page 22 of 31 file: CPA Policies/Forms/Joint Questionnaire
    • What do you think was the main reason you married this person and the main reason why you have stayed together? What do you most admire about your spouse and what do you think your spouse admires most about you? What would you most like to change about your spouse and what do you think he or she would like to have you change? What do you most like about being married? What do you like least about being married? What circumstances would make you want to consider divorce? How much time during the week do you and your spouse have alone together, and do you feel comfortable with this amount of time? Latest Revision 06/01/09 Page 23 of 31 file: CPA Policies/Forms/Joint Questionnaire
    • 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, and what happens when someone doesn’t want to do his or her chores? How do you think becoming a foster or adoptive family will affect the following situations? The amount of time you and your spouse have alone together? 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 parts of adoption or foster care do you think might cause you the most difficulty? Latest Revision 06/01/09 Page 24 of 31 file: CPA Policies/Forms/Joint Questionnaire
    • 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: Father: 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? Latest Revision 06/01/09 Page 25 of 31 file: CPA Policies/Forms/Joint Questionnaire
    • What have you disliked most about parenting? What childhood ages do you most enjoy parenting? What childhood ages do you least enjoy parenting? 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. Latest Revision 06/01/09 Page 26 of 31 file: CPA Policies/Forms/Joint Questionnaire
    • III. Please complete the remainder of the sections jointly. Couples With Children: If you have children now in your home. What is your current child care plan when you are not at home? What would this plan be after a child is placed in your home? How you think becoming a foster or adoptive parent might affect your work? 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? Latest Revision 06/01/09 Page 27 of 31 file: CPA Policies/Forms/Joint Questionnaire
    • 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 Latest Revision 06/01/09 Page 28 of 31 file: CPA Policies/Forms/Joint Questionnaire
    • Extended Family: What do you think others in your family will like best and least about having a new child in your home? IV. 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? Latest Revision 06/01/09 Page 29 of 31 file: CPA Policies/Forms/Joint Questionnaire
    • Type of home: (check one) Apartment Duplex Single-family house Mobile home Other How long have you lived here? List all other residences (addresses) where you have lived for the past 10 years. Mother Father Residence Years lived there Residence Years lived there Please attach a floor plan of your home and provide the dimensions of all rooms. On the floor plan, please indicate the room(s) where a new child/children would sleep and label the bedroom(s) “foster/adopt child’s bedroom.” Also indicate the designated indoor area, other than the bedroom(s), where the child/children would be playing and interacting with the family (i.e., family room). Label that area on the floor plan as “Indoor area where foster/adopt child plays.” 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 problems or concerns in the maintenance of your home and housekeeping standards? Latest Revision 06/01/09 Page 30 of 31 file: CPA Policies/Forms/Joint Questionnaire
    • 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? Do you own firearms? If you own firearms, where do you keep them? 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. Latest Revision 06/01/09 Page 31 of 31 file: CPA Policies/Forms/Joint Questionnaire