Foster Parent Initial Screening Questionnaire | Dallas 972-840-8130 and Houston 713-333-8686

FOSTER PARENT INITIAL SCREENING QUESTIONNAIRE

Please complete this form if you are interested in becoming an AGAPE foster parent.

Today's Date:		Referred By:
Primary Parent:		Second Parent:
Address:
City:		Zip Code:
Home Telephone:		Cell Phone:
Email:

What is your marital status: (One-year waiting period for recently married and divorced applicants. Separated applicants are not eligible to apply)	Single Married Widowed Divorced Separated Other (other explanation)
Living Arrangement: (Apartments and leased homes must have clearance from the owners for foster home and minimum of six-months lease.)	Owns Home Rented Home Apartment Other

Employed:	Wife: Yes No If yes, your job:	Husband: Yes No If yes, your job:

Education: (Require minimum of High School diploma)	Wife:	Husband:


Previous Fostering Experience: (Please explain)

Your Motivation to Foster:


List Persons Living in Your Home and Age: (Include all biological, adopted, daycare children, adult children, and adult residents)

Any Criminal History? Lived in Another State? (All foster parents and adult residents of the home require FBI fingerprint clearance. All household members 14-and-up need to submit to background check by DFPS)


Any Pets? (Guard dog breeds such as Pit Bulls, Rottweilers etc., and exotic animals such as snakes and alligators are not permitted)	Yes No If yes, breed(s) and how many:


Age, Gender, Ethnicity and Type of Children you want to Foster:

Do You Have a Respite Care Giver:	Yes No


Do You Have a Swimming Pool?	Yes No Is there a Gate Around It? Yes No

Any Trampolines at Home? (They are not permitted)	Yes No

Any Firearms or Explosive Materials? (Need current license and must be double locked)	Yes No


Do You Mind Doing Random Drug-Tests?	Yes No


Are You on Disability or have any Debilitating Medical Conditions?	Yes No If yes, please explain:


Comments: