Pre-Application Form

    Human Services Consultants
    Pre-Application Questionnaire
    Please complete this form with your current information and click on Submit.
    Last Name: Date:
    General Information
    Applicant
    Spouse
    Marital Status MarriedDivorcedSingleWidowed
     
    Home Address
    Mailing Address (if different)
    Street Address
    City
    Zip Code
    County
    Directions to your house
    from major road:
    Contact Information
    Home Phone
     
    Applicant
    Spouse
    Cell Phone
    E-mail
    List all of the members in your home:
    Name
    Gender
    Date of Birth
    Relationship to Applicant
    Home Information
    Number of Bedrooms 234567
    Bedroom for Foster Child 123
    Pool YesNo       Pool Fence YesNo
    Pets DogCatOther
    Experience
    Applicant   Spouse
    # of Years # of Years
    HCTCRegular Foster CareWorking with Children HCTCRegular Foster CareWorking with Children
    Please list any previous foster care experience:
    Please list any previous experience working with children:
    Has anyone in your home been arrested? YesNo If yes, please explain:
    Do you or anyone in your home have any health issues? YesNo If yes, please explain:
    Do you or anyone in your home have any mental health issues? YesNo If yes, please explain:
    Please explain your motivation for becoming a foster parent:
    Referred by:
    Information Source:
    Note:
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