Free 53214.FH11 - Indiana

LICENSING STAFF INQUIRY REGARDING FOSTER FAMILY HOME
State Form 53214 (3-07) / CW 3519 DIVISION OF CHILD SERVICES

Date (month, day, year)

TO:
Name of placing family case manager

ATTENTION:
Name of supervisor

FROM:
Name of licensing worker

REGARDING:
Name of foster family home

In order to assist our foster families in providing services to children, feedback is required regarding placements. Please complete this form and return to the licensing worker at the time of removal from a foster family home or the annual review, whichever comes first.
1. List the names and birthdates of children you have supervised in this home and reasons for removal, if applicable. NAME A. B. C. D. 2. How would you rate the physical standards, including housekeeping, diet, personal hygiene, and health care? Above Satisfactory Satisfactory
Explain

DATE OF BIRTH (month, day, year)

(from above-named foster family home, if applicable)

REASON FOR REMOVAL

Below Satisfactory

3. How would you rate the emotional care provided? How would you rate the effort at building and maintaining self-concept and essential connections? Above Satisfactory Satisfactory Below Satisfactory
Explain

4. Do you know how they discipline the children? Have you any concerns regarding discipline or child rearing practices? Are you aware of any abuse or neglect reports or criticism from the children, their birth family, schools, or others in the community?

5. Have these foster parents been able to work cooperatively with you and the child's family; and, if not, in what areas have there been difficulties? Have they initiated contact with you appropriately? Do they know how to reach you at all times for emergency services?

Page 1 of 2

6. From your personal experience, do you feel this family: Is overpopulated?
Explain

Has shown the capacity to handle certain types of children and problems? Would be more appropriate for a different sex or age child?

7. What is the case plan for each of your children? Have you discussed it with the foster parent(s) and shared a copy of the case plan? Do they concur, and are they cooperating? Have they been invited to case reviews and court hearings for the child(ren)?

8. Approximately how many home visits have you been able to make within the past year? What was the frequency?

9. Have you any other comments regarding strengths and weaknesses observed, or any suggestions regarding the future development and use of this home? Include, if indicated, need for additional training, support resources, referrals, etc.

Signature of placing family case manager

Date (month, day, year)

Date inquiry completed (month, day, year)

Page 2 of 2