Foster Care & Adoption Initial Assessment

Full Name *

Maiden Name *

DOB *

Spouse/Significant other's Full Name *

DOB *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Marital Status *

Email Address *

Number of Years at this residence *

Number of Years living in Florida *

Interest Pick One *

Age range interested in: *

Gender *

(If adoption only and want under age 8 refer to 1-800-96ADOPT)

How did you hear about the program? *

	TV Commercial	Radio	Billboard	Facebook	Website	All Pro Dads
Media	TV Commercial	Radio	Billboard	Facebook	Website	All Pro Dads

How did you hear about the program continued....

	Pick at least one
Church (Name of church and Denomination)	Pick at least one
Foster Parent/Friend (Name of Person)	Pick at least one
Recruitment Event (Event name/location)	Pick at least one
Child Specific (Child's Name)	Pick at least one
Referral Source: (ICPC, OTI, CMO)	Pick at least one

Do you have previous experience with Fostering in Florida or any other State? *

If yes:

	you must have at least one item
What was the name of the Agency you were previously licensed with?	you must have at least one item
Do you have a contact name and number for the agency?	you must have at least one item
Did you close your home voluntarily or did the agency recommend you home be closed?	you must have at least one item
If agency recommended closer what was the reason?	you must have at least one item