Name of Applicant(Required) First Last Name of Reference(Required) First Last 1. How long have you known the applicant(s)?(Required) 2. What is your relationship to the applicant(s)?(Required) 3. How do you know the applicant(s) and how often do you have contact with them.(Required)4. If you needed someone to care for your child, either short or long-term, would you feel comfortable using the applicant(s)?(Required) Yes No Why or why not?(Required)5. Describe how the applicants get along with each other and others (family and friends).(Required)6. Describe how the applicant(s) handle disagreements and settle differences.(Required)7. Describe how the applicant(s) relate to children.(Required)8. Describe how the applicant(s) discipline children?(Required)9. Do you think a child placed with the applicant(s) would be welcomed and accepted by their children, friends and relatives?(Required) Yes No Why or Why not?(Required)10. If a child is placed with the applicant(s) they will be given extensive, confidential information about the child’s background and birth family history. Do you think the applicant(s) will be able to keep this information confidential?(Required) Yes No Why or why not?(Required)11. Most children placed in out of home care have been abused or neglected and often have behavior problems and/or special needs.Are there behaviors or special needs of anyone in the home that might make it difficult to care for a child?(Required)How do you think the applicant(s) will respond to the extra stress caused by the placement of a child in theirhome? If the applicant(s) have children, how do you think their children will respond to the new child in theirhome?(Required)Do you think the applicant(s) would be comfortable seeking professional support (additional training, orcounseling)?(Required)What personal support systems does/do the applicant(s) have? (For example extended family, church, friends,etc.)(Required)Often the most challenging times come after a child has been in the home for a while and the “newness” is over.Do you think these applicant(s) would remain committed to a child who is exhibiting difficult behaviors over aperiod of time?(Required) Yes No Why or why not?(Required)12. Have you ever known the applicant(s) to experience problems (now or in the past) with any of the following:(Required) Drugs Alcohol Marijuana Mental Health Issues Anger Violence/ Domestic Violence Chronic difficulties with work or unemployment None of the above If marked, please explain:(Required)13. Would you recommend the applicant(s) as a placement for children?(Required) Yes No Why or why not?(Required)14. Is there anything else you feel we should consider in making a decision to place children with this applicant(s)(Required)SignaturePhone(Required)Date MM slash DD slash YYYY Untitled First Choice Second Choice Third Choice
