Hancock County Job and Family Serivces

Questionnaire For Adoptive/Foster Care Applicants

In a hundred years, it won’t matter how much money you had in the bank, what kind of car you drove, or the sort of home you had. But the world may be different because you touched the life of a child.

1.If you painted a word picture of yourself- your physical appearance and your personality- what would you see?

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2.If you painted another word picture, but this time of your spouse/significant other, what would you see?

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3.While you were growing up, what was your father like?

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4.What was your mother like as you were growing up?

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5.How was discipline handled in your home growing up? How was sex education handled? How was any conflict handled?

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6.To which parent did you feel closer while you were growing up and why?

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7.How did you get along with your brothers and/or sisters while growing up?

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8.What is your relationship like between/among your sisters and brothers today?

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9. What are your most important both positive and negative memories growing up?

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10. As you were growing up, what were your activities,interests and hobbies?

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11. What did you enjoy most and least about school?

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12. Looking back, what were your biggest problems/difficulties during your childhood?

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13. How did you meet your spouse/partner/significant other?

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14. What are the strong and weak points of your marriage/relationship?

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15. What problems/difficulties have you and your spouse/significant other faced as a couple, and how did you overcome these?

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16. Describe any issues/difficulties you and your spouse/significant other are still facing.

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17. Describe your relationship with your spouse/significant other’s family.

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18. List and describe your children.

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19. What is your motivation to foster and/or adopt children?

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20. What type and number of children are you interested in?

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21. What type of activities/hobbies do you see your child(ren) participating in? (dance, cheer, fishing, sports, etc.)

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22. What type of activities/hobbies would you enjoy doing with your child(ren)?

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23. What discipline do/will you use in your home?

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24. Would/do you and your spouse/significant other discipline differently? If so, how?

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25. What limitations do you feel you have in parenting children?

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26. Describe any experiences, training or background you have in parenting special needs children.

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27. List any special needs or type of child you feel you cannot parent:

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28. What is your occupation/career; and what do you like/dislike about it?

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29. What personal, financial, career, etc. goals do you have that you feel free to share?

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30. Have you ever been arrested, charged, or convicted of any criminal offense? If so, fully describe the incident(s) and complete the table below:

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31. Do you have any past or current mental health diagnosis? If so, describe.

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32. Do you have any past or present alcohol or drug related issues or diagnosis? If so, describe.

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33. Do you have any past or present mental health treatment or services? If so, describe.

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34. Do you have any past or present alcohol or drug related treatment or services? Is so, describe.

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35. Have you ever been recommended/advised to seek mental health treatment or services? If so, describe.

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36. Have you ever been recommended/advised to seek alcohol or drug related treatment or services? If so, describe. If yes to #31, #32, #33, #34, #35, or #36, complete the following table:

List any current or past psychotropic medications and for what diagnosis they are prescribed. Include dates.

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37. Have you or anyone in your immediate or extended family had any involvement/contact with a children services agency? If so, fully disclose who was involved, when, and any details.

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38. Is there anything further we should know that you feel is important?

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I certify that the information contained in this form is accurate and complete to the best of my knowledge. I understand that providing materially false information will prevent the agency from considering my home for placement of a child and is grounds for denial or revocation of a foster home certificate.

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