Missouri Foster Application

Foster/Adopt Home Assessment Application

Please complete all spaces accurately and completely. Application does not place you under any obligation to DFS.

II. Household Composition

Complete for everyone living in the home unless listed above. Attach additional pages, if necessary.

Complete for all children not living in the home. Attach additional pages if necessary.

III. Marital Status and History

Marital status: (S) Single, (Sep) Separated, (M) Married, (D) Divorced, (W) Widowed

Applicant 1 status: Applicant 2 status:

Former Marriage(s), if applicable

Present Marriage, if applicable

Date of marriage: Place of marriage:

Have there been any separations during this marriage? Yes No

If yes, when & how long?

IV. References

List 5 (five) people who know you well. Include 3 non-relatives and 2 relatives.

V. Supplemental Information

If you have fostered or adopted a child(ren), name source from which child(ren) was (were) obtained:

Give name of adopted child(ren), date and place of adoption(s) completed:

Have you previously applied to this agency? Yes No Result of application:

Name other agencies to which you have applied to foster or adopt:

Result of application(s):

Have you previously been studied in regard to a child custody (divorce) matter? Yes No

If yes, where and for whom?

Are you interested in more information about becoming an emergency foster home? Yes No

Why do you wish to foster or adopt a child?

Child(ren) desired: Age Range Sex Number

Would you be willing to accept a child of a race other than your own? Yes No

Would you be willing to accept a child from a different religious background than your own, and allow that child to practice his/her own religious beliefs? Yes No

Would you be willing to actively participate in the development and implementation of a treatment plan designed to provide permanency for a child? Yes No

Are you willing to participate in training sessions designed to increase your knowledge about foster/adoptive children? Yes No

Do You Understand the Following

If yes, place “Y” in the box provided. If no, place “N”. If you need more information about this topic, place an “M” in the box.

VI. Address

County of residence: Home telephone number:

Home address:

Type of home: Single family Multi-family Apartment Number of bedrooms: Number of rooms:

Directions to your home:

VII. Financial Information

A. Total monthly income: $ B. Total average monthly expenses: $

VIII. Law Violation

Has anyone living in your home ever been arrested and convicted of any law violation, other than minor traffic offenses? Yes No

If so, please give details

IX. Health

Describe the present health of all household members (please include medications, handicaps, medical conditions and mental disorders):

Please attach a photograph (if you have one) of all family members standing in front of your home.

Health Continued

Check any of the following which any family member receives or has received and please explain any items checked:

Disability Benefits

Psychiatric/Psychological Services

Physical Therapy

Individual/Family Counseling

Marital Counseling

Social Services

Special Education

Explanation of items checked:

I understand that my signature on this application gives the Division of Family Services the right to contact any individual or agency who may have information regarding my suitability for foster/adoptive parenting. My signature also certifies that information that I provide to the Division is accurate and true to the best of my knowledge.

I further understand that the foster parent licensure application process and subsequent related activity is a public record and will be made available to the public upon request. Information on pages 3 and 4 of this application, as well as supporting documentation for those pages, will not be disclosed without a court order or my written permission.