SCREENING CHECKLIST  
Name(s):  
Phone:  
Email:  
Address:  
Referral Source:  
Date of initial contact:
Adoption Foster Care
CDH ADH DCYF
Child Adult Age(s)
Male Female
Screening Taken By:
GENERAL LICENSING REQUIREMENTS
1. YES NO Are all members of the household interested in adoption/foster care?
Number of people in home:    Adults=   Children=
Sate ages of children living in the home:
2. YES NO Are you/your spouse at least 21 years old?
State ages of you/your spouse:  Female=   Male=
3. YES NO Do you have a current AZ drivers license and reliable transportation and are you willing to transport to medical appointments, visits, school, etc.?
4. YES NO

Arizona Revised Statue ARS 8-804 requires that the Department of Economic Security maintain a central registry of reports of child abuse and neglect that are substantiated and that this information be used as one factor to determine qualifications for employees of contractors that provide direct service to children. Have you or a member of your family ever had a CPS referral, involvement in a complaint involving CPS or have ever had a substantiated or unsubstantiated charge against you or a member of your family or family acquaintance or significant other in the last ten years?
5. YES NO Each adult in the household must be fingerprinted. Does anyone have an arrest record or any type of activity that would come up on a background check?
If yes, please specify:
6. YES NO Are you currently employed or have resources to meet your monthly expenses?
Male Job Title:   Hours worked:
Female Job Title:   Hours Worked:
7. YES NO Is your home large enough to accommodate another individual?
Number of bedrooms?    Share:
8. YES NO A Place To Call Home requires that all pools and spas be fenced. If you own a pool or spa, are you willing to have it fenced?
Reason/Interest in Foster Care and/or Adoption:

 

Previous Experience with Foster Care and/or Adoption:

 

Previous License or Certification:
(i.e. foster care; adoption; respite; daycare; habilitation; attendant care; etc.)

 

Prior Training:
(i.e. CPR; First Aid; CIT; CNA; RN; Surrogate Parent; etc.)

 

Availability for Training:
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