Placement Information for Ages 6-18

TODAY’S DATE:

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

In foster care since (date):
Social Security Number:

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:

School Information

Name and Location:
Time dropped off and picked up:

Contact person:
Do they need any items when they are dropped off?
After school activities?

Before and After School Care Information

Name and Location:
Time dropped off and picked up:

Contact person:

Does this child have a driver’s license? ___ YES ___ NO

Normal Weekday Schedule:

MORNING ROUTINE - Please include wake up 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 - activities
EVENING ROUTINE - Please include typical dinner time, bath time, activities and sleep time

Child’s Strengths, Needs and Interests

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

Does the child have behavioral issues or other needs?

Does the child do any of the following?

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

Favorite foods:

Least favorite foods:

Favorite shows:

Favorite activities:

General house rules in previous home:

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

Please feel free to include as much information as you wish!

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 since (date):

Licensing Social Worker and contact information:

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

Placement Information for Children Ages 6-18

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