Healthcare Foster Parent Evaluation

HEALTHCARE FOSTER PARENT EVALUATION

Purpose: This evaluation documents the foster parent's capacity to meet the medical and healthcare needs of a foster child. Information contained in this form will be used by child welfare and medical personnel for placement decisions and for ongoing healthcare planning. Information is maintained as confidential but is subject to mandatory reporting and other legal disclosures required by law.

Evaluating Clinician / Agency

Evaluation Date:    Phone:

Foster Parent Information

Date of Birth:    Gender:

Primary Phone:    Email:

Household / Placement Details

Training, Certification and Medical Competence

CPR Certified: Yes    No

First Aid Certified: Yes    No

Medication Administration Training Completed: Yes    No

Health History and Status

Ability to Manage Child Healthcare Needs

Able to administer oral medication as prescribed: Yes    No

Able to manage enteral feedings (tube feeding): Yes    No

Able to manage oxygen or respiratory equipment: Yes    No

Behavioral Health and Substance Use

Current mental health diagnosis or treatment: Yes    No

Current substance use concerns: Yes    No

Background, Safety and Legal Considerations

Background checks completed: Yes    No

Any substantiated child protection findings or current investigations: Yes    No

Authorization, Certifications and Notices

Certification of Accuracy: I certify under penalty of perjury that the information provided on this form is true and correct to the best of my knowledge. I understand that knowingly providing false information may affect foster care placement and is subject to legal consequences.

Release and Authorization: I hereby authorize healthcare providers, agencies, and relevant custodial authorities to disclose and exchange medical and behavioral health information necessary to complete this evaluation and to coordinate care for any foster child placed in my care. This authorization includes release of immunization, medication, treatment, and diagnostic records to child welfare and medical personnel involved in placement decisions.

Mandatory Reporting Notice: Medical and evaluation personnel are mandated to report suspected child abuse or neglect. Confidentiality is limited where disclosure is required by law or necessary for the child's health and safety.

Right to Withdraw: The subject may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on it. Revocation must be submitted to the evaluating agency in writing and does not affect disclosures made prior to the revocation.

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