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Questionnaires
Foster Care Specialist – DHHS
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*
" indicates required fields
User Information
If you have completed a Foster Care Placement Report within the last 60 days, you may attach a copy which can be used in place of completing this questionnaire.
Your Name
*
First
Last
Email
Name of Child/ren
If responding for more than one child, use the oldest child’s first name and last initial.
Name of Child
*
First
Last (1st initial only)
Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Board #: If Known
Meeting Date: If Known
System Contact
Did the foster parents receive adequate and/or timely background information to care for the child/ren/youth placed in their home? (medical/educational/behavioral/any other special needs)
What medication does the child/ren/youth currently take?
What are the most current dates of the following exams for the child(ren)/youth? Physical, Dental, and Vision Exam.
Do you have regular / adequate communication with the Case Manager/Probation Officer?
Do you attend team meetings?
If the child/ren/youth has a Guardian ad Litem, what was the last date of the GAL’s visit with child/ren/youth and the foster parents? Was this visit in person in the child/ren/youth placement?
Services
What services is the child/ren/youth currently receiving?
Do you feel there are services the child/ren/youth needs that they are not receiving? If so, what?
Describe the strengths and needs of the child/ren/youth.
Please describe any concerns with the child/ren/youth’s development.
Education/Wellbeing
For each child/ren/youth enrolled in school, do they have an IEP and/or a 504 Plan? If so, for what?
Describe what activities the child/ren/youth enjoys and is involved in.
Placement
Are there any concerns regarding the management of the case?
Any concerns with the court process?
Is visitation set up between the child/ren/youth and their parent/s? Have there been any concerns?
Are the foster parents willing to provide permanency for the child/ren/youth should it become necessary?
If applicable, has the Ansel Casey assessment been completed?
Additional Information
Is there anything else that you would like us to know?
Although not required, if you would like to submit any additional related documents you may do so below:
Accepted file types: pdf, xls, xlsx, doc, docx, jpg, png, gif, tiff, txt, Max. file size: 64 MB.
By returning this document, you confirm that this information is true and accurate and that you understand this information may be shared with the legal parties to the case.