Therapeutic Foster Care Parent Application

Foster Care is temporary care for children who have the ultimate goal of family reunification. This is a continuation of services provided by Heartfelt Alternatives with the same goal. According to Wake. Gov, "Foster parents play a vital role in understanding the needs of the children during these difficult times, and their help, intervention and nurturing can make all the difference to a child in need."

Mother's Name *

Father's Full Name *

Street Address *

City *

Phone *

Please detail clear dirctions to your house *

Date Of Birth * +

Place Of Birth *

Ethnicity *

Grade Last Completed *

Occupation *

Place Of Occupation *

Supervisor *

Monthly Income *

Social Security # *

Health: Has either propective parent had any serious illness, operation or chronic physical condtion? If so, Please describe:

Describe the type of child(ren), including age,sex and other details, your interested in serving. Include any special services you can offer: *

Why are you interested in being a foster parent/family? *

Are you willing to attend initial and ongoing training? *

YES

Has your family been licensed to do foster care before? *

YES

With what agency? *

Has your family applied to do foster care before? *

YES

What year? *

What are you child care plans if parent(s) work? *

Are child care options available if both parents work? If yes where? *

How did you learn about the Heartfelt Alternatives program? *

Please list the people, other than yourselves, Living in your home. Also list Date Of Birth, School or Working & Relation *

Our Family: Owns Rents *

Owns

Rents

Our family lives in: *

A House

An Apt

A Condo

A Mobile Home

Please list (3) three references other than relatives who have known you more than two years. Include Full Name, address and phone# *

Physician

I give my consent and authorization to Heartfelt Alternatives, Inc. to request, receive and share information and professional records(Medical, Educational, Psychological, social, Department of Social Services and Court) about myself and others living in my home, with various agencies and professional facilities, public or private, in order to learn about my history with my family, children and the community. I understand and agree to the application process, including interviews with my neighbors, and references.

CONFIDENTIALITY AGREEMENT

I *

being an *

of Heartfelt Alternatives, Inc. acknowledge that policies related to confidentiality have been provide and explained to me. I understan that infromation about clients and their families will be shared with me for the purpose of providing foster care services. I also understand that this information is shared with others only when there is a need to know and when there is a written working agreement between agencies, or a specific signed release for information has been executed. I also understan that this information cannor be shared with individuals and /or agencies that have no direct need for the information. I further understand that my employment/relationship can be terminated if I voilate the agency's confidentiality police. Inderstand and I am willing to comply with these confidentiality requirements.

Employee/Foster Parent/Volunteer *

clear

Date * +

Employee/Foster Parent/Volunteer *

clear

Date * +

Executive Director or Designee *

clear

Date * +

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