Free 53213 Proof.FH11 - Indiana

ANNUAL REPORT REGARDING FOSTER FAMILY HOME
State Form 53213 (4-07) / CW 3518 DEPARTMENT OF CHILD SERVICES

County or agency Name of Applicant A Address (number and street, city, state, and ZIP code) Name of Applicant B Address (number and street, city, state, and ZIP code) Home telephone number

FH number Date of birth (month, day, year) Race

Date of birth (month, day, year)

Race

(

)

Other telephone number

(

)

Beginning of licensing period (month, day, year)

End of licensing period (month, day, year)

CHILDREN NAME RACE RELATIONSHIP DATE OF BIRTH
(month, day, year)

CURRENT FOSTER CHILDREN NAME NAME

Page 1 of 3

FORMER FOSTER CHILDREN (since last license) NAME NAME

1. Changes: Indicate any changes in foster family situation since the last license.
Employment Explanation

Yes
Health

No
Explanation

Yes
Financial Status

No
Explanation

Yes
Living arrangements

No
Explanation

Yes
Family composition

No
Explanation

Yes

No

2. Has the foster parent(s) demonstrated an understanding of the foster parent role in relationship to the agency?

3. Has the foster parent(s) demonstrated an understanding of the foster parent role in relationship to the child?

4. Has the foster parent(s) demonstrated an understanding of the foster parent role in relationship to the birth parents?

5. Has the foster parent(s) demonstrated an understanding of the use of appropriate discipline?

Page 2 of 3

6. Type of child requested by foster family:

7. Summarize the strengths of the foster family:

8. Summarize areas in which the foster family might require support services:

9. Foster parent comments:

10. Recommendations:

REPORT PREPARED BY
Signature of licensing worker Signature of supervisor Date (month, day, year) Date (month, day, year)

Page 3 of 3