Placement Information for Children Ages 0-5

This is a recommended list of questions to ask when preparing to place a child in your home.

TODAY’S DATE:

Child’s Name:                                                                   
Date of birth:
Social Security Number:
Gender:  __ male     __ female                    Age:                                     Ethnicity:

In foster care since (date):

Child’s Child’s Social Worker 
Name:                                                  
Email:                                               Office phone:                                    Mobile Phone:

Child’s Child’s Social Worker Supervisor        
Name:                                                  
Email:                                                                                        Office phone:             

Child’s Child’s Guardian Ad Litem 
Name:                                                  
Email:                                                                                        Phone:             

Previous Foster Parent(s) 
Name:                                              
Email:                                                                                        Phone:              

Family Information

Mother’s name:                                                          
Father’s name:
Siblings and their ages:
Other family members close with this child:

Does the child have regularly scheduled visitations with his/her parents and family members?

DAY    /     FREQUENCY     /      LOCATION     /    TIME     /     DESCRIPTION

Medical Information

Doctor’s name:                                                     Office name and location:

Dentist’s name:                                                     Office name and location:

Does the child see a mental health professional?  __ Yes __ No             
 If so, who and how often?

Mental health professional’s  name:                                                    
Office name and location:

Allergies:

Medications:

Medical concerns:

About the Child

Child’s weight:

Shirt size:                     Pant size:                      Shoe size:                   Diaper size:

If the child is enrolled in daycare, where do they go?
Location:
Time dropped off / Time picked up:
Contact person:
Do they need any items when dropped off?

What are the child’s strengths, interests and activities?

Does the child have behavioral issues or other special needs?

 Does the child do any of the following?

__ swear  __ hit      __ bite     __ kick  __ run away   __ soil pants   __ wet bed
Other:

Normal Weekday Schedule:
MORNING ROUTINE - Please include wake up time and activities
DAYTIME - Nap time and activities
EVENING ROUTINE - Please include typical dinner time, bath time, activities and sleep time

Normal Weekend Schedule:
MORNING ROUTINE  - Please include wake up time and activities
DAYTIME   - Nap time and activities
EVENING ROUTINE  - Please include typical dinner time, bath time, activities and sleep time

Favorite foods or formula brand:

Favorite books:

Favorite shows:

Favorite activities:

General house rules:

 Any other notes about this child that will make it easy for their transition?

FOSTER PARENT CHECKLIST

Your child’s social worker should deliver the following. Make sure to follow up on these items if you do not receive them.

• Placement Letter

• Medical Card

• Clothing Allowance

• Monthly Allowance 

When is the next court hearing for this child?   
Date:                                   Time:

Does this child have a life book started?  

FOSTER PARENT INFORMATION FOR CHILD’S SOCIAL WORKER

Foster parent name:
Email:                                                                                        Phone:          

Foster parent name:  
Email:                                                                                        Phone:          

Foster parent since (date):

Licensing Social Worker and contact information:

Any other information you would like the child’s social worker to know?