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Restored Hope Therapeutic Foster Care
Reviving Lives, Repairing Dreams and Restoring Hope
Karen Cowan, Administrator Janice Franklin, Program Director
65 Walton Street
Asheville, NC 28801
828.225.6520
Dear Prospective Foster Parent,
Thank you for your inquiry into our Therapeutic Foster Care Program. We appreciate the opportunity to get to know you and your family further, and to decide together whether we are the right agency for you.
Enclosed, please find and read over the Therapeutic Foster Care applications. We request that you complete an application for our agency to review. Once your completed applications are returned to the agency, a determination will be made regarding the appropriateness of an interview. You will receive notice from Restored Hope as to the outcome of this determination in a timely fashion.
Again, thank you for your interest in our program and we look forward to receiving your application.
Respectfully,
Janice
Janice Franklin
Program Director
Restored Hope
RESTORED HOPE
THERAPEUTIC FOSTER CARE
65 Walton Street
Asheville, North Carolina 28801
Telephone No.: 828.768.8818
INFORMATION IS KEPT STRICTLY CONFIDENTIAL.
THERAPEUTIC
PARENTING APPLICATION
Check the program or programs that you are interested in:
Treatment Foster Care: Date
Emergency/Short Term Crisis Care Only:
Respite Care:
Wife or Single Female: ______
(First) (Middle) (Last Name)
Social Security #______Driver License #______DOB:______
Address: ______(Street address)
______(City) (State) (Zip)
Home Phone: ______Business Phone(s): ______
Do you receive calls at work? Yes No
Husband or Single Male: ______
(First) (Middle) (Last Name)
Social Security# ______Driver License #______DOB:______
Business Phone(s): ______Do you receive calls at work? Yes No
E-mail Address:______
Directions for finding your home: ______
______
______
______
______
______
______
hUSBAND / WifeDate of Birth / Date of Birth
Place of Birth
City:
State: / Place of Birth
City:
State:
Race
Nationality / Race
Nationality
Last Grade Completed
Or
Degree Received / Last Grade Completed
Or
Degree Received
Religious Affiliation / Religious Affiliation
Occupation / Occupation
Present Employer
Address / Present Employer
Address
Annual Salary $00-10,000 40-50,000
Check One $20-30,000 50,000-up / Annual Salary $00-10,000 40-50,000
Check One $20-30,000 50,000-up
Other Income
and Source: / Other Income
and Source:
Estimate Monthly expenses / Estimate Monthly expenses
Physicians or Clinic / Physicians or Clinic
Any Medical Conditions / Any Medical Conditions
Any Hospitalizations if yes give date(s) / Any Hospitalizations if yes give date(s)
Name of Hospital(s) / Name of Hospital(s)
Reasons for Hospitalization(s) / Reasons for Hospitalization(s)
Outpatient Psychiatric Treatment
Yes No / Outpatient Psychiatric Treatment
Yes No
Inpatient Psychiatric Treatment
Yes No / Inpatient Psychiatric Treatment
Yes No
HUSBAND / WIFE
Have you ever been convicted of an offense against the law other than a minor traffic violation?
Yes No
If yes, explain on a separate sheet and give date. / Have you ever been convicted of an offense against the law other than a minor traffic violation?
Yes No
If yes, explain on a separate sheet and give date.
Have you ever been investigated for child abuse or neglect?
Yes No / Have you ever been investigated for child abuse or neglect?
Yes No
If yes, was it substantiated?
Yes No
If yes, explain on a separate sheet and give date, county and state of occurrence. / If yes, was it substantiated?
Yes No
If yes, explain on a separate sheet and give date, county and state of occurrence.
Present Marriage: Date:
City:
State: / Present Marriage: Date:
City:
State:
Previous Marriages
Yes No
To Whom:
Date of Separation:
Date of Divorce:
Date of Death: / Previous Marriages
Yes No
To Whom:
Date of Separation:
Date of Divorce:
Date of Death:
CHILDREN OF THIS MARRIAGE:
Name: Last, First, Middle-DOB-Current Address-Grade-School-Birth/Adoption
______
______
______
______
CHILDREN FROM PREVIOUS MARRIAGES:
Husband / wifeName
Birthdate
Address
Birth Adopted / Name
Birthdate
Address
Birth Adopted
Name
Birthdate
Address
Birth Adopted / Name
Birthdate
Address
Birth Adopted
Name
Birthdate
Address
Birth Adopted / Name
Birthdate
Address
Birth Adopted
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Beginning with this page both husband and wife need to fill out SEPARTELY
REFERENCES (PLEASE LIST ONE RELATIVE AND THREE NON-RELATIVES)
NAME COMPLETE MAILING ADDRESS
Relative: ______
Non-
Relatives:______
______
______
PLACEMENT INFORMATION
A. Have you ever applied for a child from another source? ______
Date: ______What source?______
Was there a placement? ______Date: ______
Foster Care: ______Adoptive: ______
What is the status of your application? ______
B. What type of child do you believe would fit into your family and why? (Age, sex, race, handicaps, sibling group.)______
______
______
______
C. Why are you interested in taking a child in at this time? ______
______
______
D. Could you accept placement of more than one child at one time? ______Maximum:______
E. Where did you hear about our Therapeutic Foster Care Programs?
______
______
F. How has your family prepared itself for accepting a child? How do you think your children will react to sharing their home and their parents' attention?
______
______
G. What do you think that you and your family have to offer a child?
______
______
______
______
H. How do you feel that your past experiences have prepared you to become a foster parent? Include direct experiences with children.
______
______
______
______
______
______
______
______
______
______
______
______
______
I. Please indicate the age range and sex of children with whom you would prefer (P) and be willing (W) to work.
Boys Girls
Under 8 Under 8
8-9 8-9
10-13 10-13
14-16 14-16
17-18 17-18
J. Most people have some worries, or doubts, about working with emotionally disturbed youths. What are your greatest concerns about having such a child in your home?
______
______
______
______
______
K. All people have different things that really bug them. How bothered would you be if your foster child: (Try to take some time and imagine)
(Check One)
Not at Very Quite Very
All Little Some A Bit Much
1. Lies
2. Steals
3. Destroys property in
your home
4. Curses
5. Pouts, gets sullen
6. Runs away
7. Wets the bed
8. Is constantly on the go
& getting into things
9. Is under active, never
wants to do anything
10. Has many physical
complaints
L. Why would you consider keeping a foster child with behavior problems?
(Check One)
Not at Very Quite Very
All Little Some A Bit Much
1. To get a playmate for my
own children
2. To add to the family
income
3. Because of the warmth I
feel for children
4. Children is needed for a
strong marriage
5. Because I would enjoy the
challenge of a difficult
task
6. Because I want to have a
child of my own to care for
7. Because I know that I am
a good parent
8. Because the children
need loving parents
9. Because I am generally
interested in the project
and in helping people
10. Because I had problems as
a child and can understand
problem children
11. Because I would be better
able to do God's work
Please return completed application to:
Restored Hope
Therapeutic Foster Care
65 Walton Street
Asheville, NC 28801
Attn: Janice Franklin