KINSHIP PROFILE QUESTIONNAIRE

INSTRUCTIONS:  Complete as much of this form as possible.  If you have problems completing this form, please contact the worker who sent this form to you for assistance.  If a question does not apply to you, write N/A (Non-Applicable).

Name of home being studied:
Address:
City:
County:
Home phone:
Cell phone numbers (all available):

Email address:
Direction to home from center of nearest town.

Identity of household members:
CAREGIVER #1:
Full Legal Name:		
	(First)	(Middle)	(Last) 	
		
Any other names you have used (note maiden and other married names.):		
		
Birth date		Race: 	Birthplace	(city, county, state)	
		
Height			Weight			Hair Color			Eye Color		
		
Race/Ethnicity		
Religious Affiliation:		
		
Military Record:		
		
	Branch of Service			Dates of Service		
						
	Highest Rank Obtained			Type of Discharge		
						
	Work Performed in Service		

Primary Language:
Other languages spoken:
US Citizen: 
Date of citizenship:

Criminal Record:		
		
	Have you ever been convicted	  Yes	  No	If yes, give the nature of the charges and disposition 	
					
	of charges		

Education:	
					
	Highest school grade completed			When completed?		
					
	Where completed		
					
	College years completed			Degree		
					
	List any special training you have received and where it was received		

	

CAREGIVER #2:
Full Legal Name:		
	(First)	(Middle)	(Last) 	
		
Any other names you have used (note maiden and other married names.):		
		
Birthdate		Race: 	Birthplace	(city, county, state)	
		
Height			Weight			Hair Color			Eye Color		
		
Race/Ethnicity		
Religious Affiliation and last church attended::		
		
Military Record:		
		
	Branch of Service			Dates of Service		
						
	Highest Rank Obtained			Type of Discharge		
						
	Work Performed in Service		

Primary Language:

Other languages spoken:

US Citizen:                                          Date of citizenship:  

Criminal Record:		
		
	Have you ever been convicted	  Yes	  No	If yes, give the nature of the charges and disposition 	
					
	of charges		

Education:	
					
	Highest school grade completed			When completed?		
					
	Where completed		
					
	College years completed			Degree		
					
	List any special training you have received and where it was received		

	

Identify child or children to be placed:
For each include if known:

Name:							DOB:

Height: 		Weight: 		Hair color: 			Eye color:

Place of birth (City, County, State):

Note any difficulties in birth (Natural birth, C-section, other problems):

Note any developmental delays, were milestones met on time?

Describe unusual needs or behaviors of child:

Current grade in school: 

Note any current disabilities:

Describe current health:

Name of child’s doctor and city:

Name child’s dentist and city:

Religious affiliation and last church attended:

Name:							DOB:

Height: 		Weight: 		Hair color: 			Eye color:

Place of birth (City, County, State):

Note any difficulties in birth (Natural birth, C-section, other problems):

Note any developmental delays, were milestones met on time?

Describe unusual needs or behaviors of child:

Current grade in school: 

Note any current disabilities:

Describe current health:

Name of child’s doctor and city:

Name child’s dentist and city:

Religious affiliation and last church attended:

Name:							DOB:

Height: 		Weight: 		Hair color: 			Eye color:

Place of birth (City, County, State):

Note any difficulties in birth (Natural birth, C-section, other problems):

Note any developmental delays, were milestones met on time?

Describe unusual needs or behaviors of child:

Current grade in school: 

Note any current disabilities:

Describe current health:

Name of child’s doctor and city:

Name child’s dentist and city:

Religious affiliation and last church attended:

Caregiver’s Motivation:
State reasons you believe the child should be placed with you and your beliefs about the child’s/children’s permanent placement. Why do you want the children placed with you?

History of alcohol or drug abuse if any, give dates of any DWI or DUI.

History of child abuse/neglect as a child.

History of child abuse/neglect as an adult accused of abuse or neglect.

History of any criminal offense other than minor traffic offenses.

Family Relationships:

Caretaker #1: 
Full Name (include maiden and any married names used): 				Place of birth:

Name of biological father:				Age/DOB: 	
		
Address and phone number:				Frequency of contact:

Current health status and cause of death if deceased:

Name of biological mother: 				Age/DOB:
Address and phone number: 				Frequency of contact:
Current health status and cause of death if deceased:

Describe home life and discipline received as a child.

Discuss relationship with both parents as a child, include stepparents or other caregivers who were primary parents for you.

Describe financial level of home (generally low, middle, high income).

Last grade completed in school and favorite subject.
Note participation if any in team sports.

List siblings in order, oldest first:
Name: 					Age/DOB:
Address and phone number:						Frequency of contact:
Marital state: 				Number of children
Current health status or cause of death if deceased:

Name: 					Age/DOB:
Address and phone number:						Frequency of contact:
Marital state: 				Number of children
Current health status or cause of death if deceased:

Name: 					Age/DOB:
Address and phone number:						Frequency of contact:
Marital state: 				Number of children
Current health status or cause of death if deceased:

Name: 					Age/DOB:
Address and phone number:						Frequency of contact:
Marital state: 				Number of children
Current health status or cause of death if deceased:

Add for each sibling and for any half siblings.

Describe relationship with siblings while children and current relationship.

Marriages   (If none, so state):
Age at first significant relationship and with whom, give name and age and note how you met.

How long did you date?
Date and place (county) of marriage or date moved in together.
Children born to this relationship:
Note for each child or stepchild in your care:
Name: 						DOB:
Current address and phone number: 					Frequency of contact:
Note childhood development and milestones met on time.
Current health.

Name: 						DOB:
Current address and phone number: 					Frequency of contact:
Note childhood development and milestones met on time.
Current health.

Add the above information for each child of the relationship.

Discuss the quality of the marriage or relationship, note if there was ever any domestic violence, and if the relationship has ended, state why it ended.

List remaining marriages ending with the current marriage or relationship.

Age at next relationship? 		Who was this relationship with, give name, age, and how met.
How long did you date? 			Date of marriage or date moved in together:
Date and place (county) of marriage or date moved in together.
Children born to this relationship:
Note for each child or stepchild in your care:
Name: 						DOB:
Current address and phone number: 					Frequency of contact:
Note childhood development and milestones met on time.
Current health.

Name: 						DOB:
Current address and phone number: 					Frequency of contact:
Note childhood development and milestones met on time.
Current health.

Add the above information for each child of the relationship.

Discuss the quality of the marriage or relationship, note if there was ever any domestic violence, and if the relationship has ended, state why it ended.

Repeat the above for each marriage or relationship.

Describe current marriage or relationship. (Include level of mutual satisfaction in all areas of the relationship, state if any domestic violence, note shared interests, feelings about children, shared hobbies, and what you would do should conflicts develop in the relationship).

Family Rules and Boundaries:
Discuss assignment of chores and rules of the house?

Discipline:
How is discipline handled?

Child care knowledge:
Discuss past and current child care experience.

Child Management:
How have you dealt with problem behaviors in the past? 
Discuss how you plan to deal with such problems when they occurr?

Permanency:
How long have you been involved in the lives of the child or children? Include approximately how many times the child has been in contact with you and how many nights has the child spent in your home?

MEDICAL HISTORY Caregiver 1:

Have you had a history of or treatment for any of the following?
	No	Yes		No	Yes		No	Yes	
Tuberculosis			Depression			Alcoholism			
Cancer			Seizures			Asthma			
Severe Arthritis			Heart Condition			Chronic Headaches			
Chronic Kidney Condition			Mental/Emotional Problems			Chronic Fatigue			
Colitis			Ulcers			Insomnia			
Eczema			Hemophilia			Allergies			
Hay fever			Diabetes			Other:			

Have you ever received treatment for a mental illness?                            No                           Yes

If so, when and who gave treatment:                                                                                                                                                        

Have you taken medication for mental or emotional problems?                               No                           Yes

                When:                                                                                                     

                Drug(s) Prescribed:                                                                                                                                                                                

Have you ever intentionally hurt yourself or attempted to commit suicide?                             No                           Yes

If so, when and why?                                                                                                                                                                                                              

Have you ever gone to counseling for emotional or family problems?                     No                           Yes

If so, when and who was the counselor?                                                                                                                                                                 

Have you ever had a psychological examination or battery of psychological tests?                 No                           Yes

If so, when did you receive the psychological exam, and what was your diagnosis?                                                                                                               

If you are an adult, are you physically able to have children?                  No                           Yes

If no, why not?                                                                                                                                                                                 

List all admissions to the hospital

Date	Place	Reason for Admission	

			

List all prescription medications being taken on a regular basis.

Medication	Reason for Medication	

		

Date of last visit to doctor and reason:                                                                                                                                                                  

List all illnesses you have had in the past year:                                                                                                                                                       

Do you have a physical disability?                          No                           Yes          If yes, please explain                                                                               

Have you ever been treated for drug usage?                             No                           Yes          If yes, when and where?                                                          

Have you ever been treated for alcoholism?                            No                           Yes          If yes, when and where?                                                          

A statement may be needed from a physician, psychologist, or counselor concerning you and /or your child's past or current physical, mental or emotional condition.  Are you willing to give permission for release of such information, if necessary?

                No                           Yes

Caregiver 1: EMPLOYMENT:
Include a brief statement of jobs worked while in school, place and type of first job following leaving school. 	

	
Current employer	Position	Phone No.	
Address			Starting Date	
Type of Work Performed	

		

Previous employment for last 5 years if different from present employment
(If needed, use back of page)	
Employer’s Name	Position	Phone No.	
Address		Starting Date	Ending Date	
Reason For Leaving	

					
					
Hobbies:	

Child Support:			Is Payment
Current?	
Name(s) of Child(ren), DOB	Amount of Child
Support Payment	Automatic
Deduction by
Employer	
		  Yes     No	
		  Yes     No	
		  Yes     No	
		  Yes     No		
					
Do you visit your children?	  Yes              No	If Yes, how often?		
					
If No, why?		

Caretaker #2: 
Name: 				Place of birth:
Name of biological father:				Age/DOB: 			
Address and phone number:				Frequency of contact:
Current health status and cause of death if deceased:
Name of biological mother: 				Age/DOB:
Address and phone number: 				Frequency of contact:
Current health status and cause of death if deceased:

Describe home life and discipline received as a child.
Discuss relationship with both parents as a child, include stepparents or other caregivers who were primary parents for you.

Describe financial level of home (generally low, middle, high income).

Last grade completed in school and favorite subject.
Note participation if any in team sports.

List siblings in order, oldest first:
Name: 					Age/DOB:
Address and phone number:						Frequency of contact:
Marital state: 				Number of children
Current health status or cause of death if deceased:

Name: 					Age/DOB:
Address and phone number:						Frequency of contact:
Marital state: 				Number of children
Current health status or cause of death if deceased:

Name: 					Age/DOB:
Address and phone number:						Frequency of contact:
Marital state: 				Number of children
Current health status or cause of death if deceased:

Name: 					Age/DOB:
Address and phone number:						Frequency of contact:
Marital state: 				Number of children
Current health status or cause of death if deceased:

Add for each sibling and for any half siblings.

Describe relationship with siblings while children and current relationship.

Marriages   (If none, so state):

Age at first significant relationship and with whom, give name and age and note how you met.
How long did you date?
Date and place (county) of marriage or date moved in together.
Children born to this relationship:
Note for each child or stepchild in your care:
Name: 						DOB:
Current address and phone number: 					Frequency of contact:
Note childhood development and milestones met on time.
Current health.

Name: 						DOB:
Current address and phone number: 					Frequency of contact:
Note childhood development and milestones met on time.
Current health.

Add the above information for each child of the relationship.

Discuss the quality of the marriage or relationship, note if there was ever any domestic violence, and if the relationship has ended, state why it ended.

List remaining marriages ending with the current marriage or relationship.

Age at next relationship? 		Who was this relationship with, give name, age, and how met.
How long did you date? 			Date of marriage or date moved in together:
Date  and place (county) of marriage or date moved in together.
Children born to this relationship:
Note for each child or stepchild in your care:
Name: 						DOB:
Current address and phone number: 					Frequency of contact:
Note childhood development and milestones met on time.
Current health.

Name: 						DOB:
Current address and phone number: 					Frequency of contact:
Note childhood development and milestones met on time.
Current health.

Add the above information for each child of the relationship.

Discuss the quality of the marriage or relationship, note if there was ever any domestic violence, and if the relationship has ended, state why it ended.

Repeat the above for each marriage or relationship.

Describe current marriage or relationship. (Include level of mutual satisfaction in all areas of the relationship, state if any domestic violence, note shared interests, feelings about children, shared hobbies, and what you would do should conflicts develop in the relationship).

Family Rules and Boundaries:
Discuss assignment of chores and rules of the house?

Discipline:
How is discipline handled?

Child care knowledge:
Discuss past and current child care experience.

Child Management:
How have you dealt with problem behaviors in the past? 
Discuss how you plan to deal with such problems when they occurr?

Permanency:
How long have you been involved in the lives of the child or children? Include approximately how many times the child has been in contact with you and how many nights has the child spent in your home?

MEDICAL HISTORY Caregiver 1:

Have you had a history of or treatment for any of the following?
	No	Yes		No	Yes		No	Yes	
Tuberculosis			Depression			Alcoholism			
Cancer			Seizures			Asthma			
Severe Arthritis			Heart Condition			Chronic Headaches			
Chronic Kidney Condition			Mental/Emotional Problems			Chronic Fatigue			
Colitis			Ulcers			Insomnia			
Eczema			Hemophilia			Allergies			
Hay fever			Diabetes			Other:			

Have you ever received treatment for a mental illness?                            No                           Yes

If so, when and who gave treatment:                                                                                                                                                        

Have you taken medication for mental or emotional problems?                               No                           Yes

                When:                                                                                                     

                Drug(s) Prescribed:                                                                                                                                                                                

Have you ever intentionally hurt yourself or attempted to commit suicide?                             No                           Yes

If so, when and why?                                                                                                                                                                                                              

Have you ever gone to counseling for emotional or family problems?                     No                           Yes

If so, when and who was the counselor?                                                                                                                                                                 

Have you ever had a psychological examination or battery of psychological tests?                 No                           Yes

If so, when did you receive the psychological exam, and what was your diagnosis?                                                                                                               

If you are an adult, are you physically able to have children?                  No                           Yes

If no, why not?                                                                                                                                                                                 

List all admissions to the hospital

Date	Place	Reason for Admission	

			

List all prescription medications being taken on a regular basis.

Medication	Reason for Medication	

		

Date of last visit to doctor and reason:                                                                                                                                                                  

List all illnesses you have had in the past year:                                                                                                                                                       

Do you have a physical disability?                          No                           Yes          If yes, please explain                                                                               

Have you ever been treated for drug usage?                             No                           Yes          If yes, when and where?                                                          

Have you ever been treated for alcoholism?                            No                           Yes          If yes, when and where?                                                          

A statement may be needed from a physician, psychologist, or counselor concerning you and /or your child's past or current physical, mental or emotional condition.  Are you willing to give permission for release of such information, if necessary?

                No                           Yes

Caregiver 1: EMPLOYMENT:
Include a brief statement of jobs worked while in school, place and type of first job following leaving school. 	

	
Current employer	Position	Phone No.	
Address			Starting Date	
Type of Work Performed	

		

Previous employment for last 5 years if different from present employment
(If needed, use back of page)	
Employer’s Name	Position	Phone No.	
Address		Starting Date	Ending Date	
Reason For Leaving	

					
					
Hobbies:	

Child Support:			Is Payment
Current?	
Name(s) of Child(ren), DOB	Amount of Child
Support Payment	Automatic
Deduction by
Employer	
		  Yes     No	
		  Yes     No	
		  Yes     No	
		  Yes     No		
					
Do you visit your children?	  Yes              No	If Yes, how often?		
					
If No, why?		

Past residences
List addresses lived for the past 10 years, noting the years spent at each.

PRESENT HOUSEHOLD:	

Address			Phone No.		
					
How long have you lived at this address?		
					
Is this address a:	   House	   Mobile Home	   Apartment		
					
How many rooms do you have?			How many bedrooms?			How many baths?		

					
	
Smoke detectors, state where: ____
Fire extinguishers, note where: ____
For children 3 yrs and younger, are exposed electric outlets covered or protected?___
For any guns in the home, are they kept under lock with ammunition locked in a separate place?___

CHILD CARE ARRANGEMENTS:	

	

	

	

	

When both parents are working or away from home, who cares for the children?	

	

	

Name / Facility Name	
Age of Caregiver
(If not a Facility)	
Phone Number	

	

	

	

	

	

	

Are the children current on their immunizations?                                         No                           Yes

If not, why?                                                                                                                                                                                                          

	

MONTHLY BUDGET:	
					
INCOME	GROSS		TAKE HOME	
Husband’s Monthly Income.............................................. 				
Wife’s Monthly Income.................................................... 				
Other Monthly Income (Child Support, Rent, etc.)........................ 				
TOTAL INCOME.......................................................... 				
				
MONTHLY EXPENSES			AMOUNT OWED	
House Payment (Rent/Mortgage)........................................................................ 			
Payments on Other Real Property....................................................................... 			
Automobile Payment........................................................................................... 			
Automobile Expenses (Gas/Upkeep)................................................................... 			
Food..................................................................................................................... 			
Utilities (Electricity, gas, water, etc.).................................................................. 			
Telephone Expenses............................................................................................. 			
Revolving Charge Accounts (Visa, Sears, etc.)................................................... 			
Insurance.............................................................................................................. 			
            Life........................................................................................................... 			
            Health/Hospitalization............................................................................. 			
            Auto......................................................................................................... 			
            Property.................................................................................................... 			
Medical/Dental Expenses.................................................................................... 			
Clothing............................................................................................................... 			
Furniture.............................................................................................................. 			
Church Contributions.......................................................................................... 			
Entertainment...................................................................................................... 			
Support of Relatives............................................................................................ 			
Miscellaneous (Specify)....................................................................................... 			
TOTAL MONTHLY EXPENSES.................................................................. 			

Financial status:
Discuss how you plan to care for additional children in the home.

Note if you have life insurance. If so what is the face amount and who is covered.

Note if you have a major medical insurance policy. Who is covered and can the children being placed be added to the policy?

List the relatives or friends you plan to use as your primary support system should you need help. Include names, addresses, and phone numbers.

PEOPLE WHOM WE CAN TALK TO THAT KNOW YOU WELL:

1.	Name			Address		
						
	Relationship					
						
	Day Phone No.			Night Phone No.		

2.	Name			Address		
						
	Relationship					
						
	Day Phone No.			Night Phone No.		

3.	Name			Address		
						
	Relationship					
						
	Day Phone No.			Night Phone No.		

4.	Name			Address		
						
	Relationship					
						
	Day Phone No.			Night Phone No.		

5.	Name			Address		
						
	Relationship					
						
	Day Phone No.			Night Phone No.		

6.	Name			Address		
						
	Relationship					
						
	Day Phone No.			Night Phone No.		

Do you have firearms in the home?	  Yes               No	If yes, what type of gun(s) and where/how stored: (under lock with ammunition locked in a separate compartment is the requirement.)

Where are medications stored?

Where are poisons and cleaning supplies stored?

Where is gasoline and other dangerous products stored?

	

COMMENTS (any additional information you feel will be helpful):

	

	

	

	

WE AFFIRM THAT THE ANSWERS WE HAVE PROVIDED ARE ACCURATE TO THE BEST OF OUR KNOWLEDGE.	

							
Signature		Date	Signature	Date