Care Giver Questionnaire – DHHS - Foster Care Review Office

Caregiver Questionnaire – DHHS

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User Information

This survey is for anyone who is providing the 24/7 care of the child/youth, regardless of the placement type.

What is reported in this questionnaire may be included in the local board’s report to the legal parties to the case.

Your Name*

First Last

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 State / Province / Region

Board #: If Known

Meeting Date: If Known

System Contact

Did you get the information you needed to care for the child/ren/youth when they were placed with you? Explain.

Do you have enough ongoing communication with the case manager? Explain.

Does the child/ren/youth’s attorney, the GAL, visit the child/ren/youth? Explain.

Do you get the information and/or support you need from your foster care agency and/or other providers? i.e. – visitation provider?

You have a right to be notified and attend court hearings. Do you attend these court hearings? If not, why not?

About the Child/ren/youth placed in your home

Tell us about the child/ren/youth’s strengths, interests, positive and negative behaviors, etc.

What activities do the child/ren/youth participate in with you as a family or in the school/community?

Does your child/ren need anything in order to be able to participate in these activities? Explain.

Are the child/ren/youth developmentally on track? Explain any delays or disabilities

What services are the child/ren/youth receiving, if any?

Please list any additional services the child/ren/youth need, if any:

Education/Wellbeing

Do the child/ren/youth attend daycare?

Yes

Are the child/ren/youth enrolled in and attending school? Any extra-curricular activities?

Does the child/ren/youth have an IEP/504 plan? If applicable, what is the IEP/504 plan for?

Are there educational concerns that are not being addressed?

Youth(s) 14+ years old

Describe the age-appropriate life skills the youth(s) is learning/developing:

Does the youth(s) have a learner’s permit, driver’s license, a part-time job etc. If yes, please list:

If the youth(s) is 18 years or older, do they have access to their Social Security Card, birth certificate, medical and educational records, pictures, etc. in preparation for turning 19?

If not, what is needed?

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.