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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Human Services Consultants

4449 N. 12th Street
Phoenix, AZ 85014

Phone: (602) 279-1427

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