YUROK SOCIAL SERVICES
Yurok tribal design
Foster Care Inquiry Form

Names Address Home Telephone

HOUSEHOLD MEMBER ONE:

DOB Ethnicity Gender Work Phone Cell Phone
Is it ok to contact you via these #'s?YesNo If only one, which?WorkHome

HOUSEHOLD MEMBER TWO

DOB Ethnicity Gender

Work Phone Cell Phone
Is it ok to contact you via these #'s?Yes No If only one, which?WorkHome

CHILDREN ALREADY IN YOUR FAMILY

Name DOB Gender Birth Adopted Foster Guardian
Name DOB Gender Birth Adopted Foster Guardian
Name DOB Gender Birth Adopted Foster Guardian
Name DOB Gender birth Adopted Foster Guardian

CHARACTERISISTICS OF CHILD DESIRED FOR FOSTER PLACEMENT

Male Female Either Both # of Children Ages:0-2 3-6 7-10 11-14 15-18

SPECIAL NEEDS OF A CHILD YOU WILL CONSIDER

Behavioral Issues History of Sexual Abuse Learning Disabilities Mental Health Issues Mental Illness of Parents Developmental Delays

LEVEL OF LEGAL RISK FOR CHILD TO BE REUNIFIED

Low Legal Risk Moderate Legal Risk High Legal Risk

ARE YOU LISCENSED FOR FOSTER CARE?YesNo COUNTY/AGENCY