Are there any issues or circumstances that visitation center should be aware of with respect to the children such as allergies, fears, special needs, etc? Current Foster/ Relative Placement #1 Child(ren) Placed in This Home: Placement Type: Placement Name(s): County: Address: Phone: City/ State: Relation: If placement is a relative or biological parent, please answer the following: DOB: Last 4 digits of SSN: Ethnicity: Marital Status: Highest grade or level completed: Household Income Sources (check all that apply): Estimated Household Income Less than $10,000 Full-time employment Relative Subsidy Unemployment $10,000 - $19,999 Part-time employment Retirement VA Veteran’s Admin – $20,000 - $29,999 Food Stamps Social Security WIC $30,000 - $39,999 Child Support SSI Workman’s Comp $40,000 - $49,999 Private disability insurance TANF Other More than $50,000 If more than one Foster/ Relative Placement #2 Child(ren) Placed in This Home: Placement Type: Placement Name(s): County: Address: Phone: City/ State: Relation: If placement is a relative or biological parent, please answer the following: DOB: Last 4 digits of SSN: Ethnicity: Marital Status: Highest grade or level completed: Household Income Sources (check all that apply): Estimated Household Income Less than $10,000 Full-time employment Relative Subsidy Unemployment $10,000 - $19,999 Part-time employment Retirement VA Veteran’s Admin – $20,000 - $29,999 Food Stamps Social Security WIC $30,000 - $39,999 Child Support SSI Workman’s Comp $40,000 - $49,999 Private disability insurance TANF Other More than $50,000 If more than two Foster/ Relative Placements #3 Child(ren) Placed in This Home: Placement Type: Placement Name(s): County:
Are there any issues or circumstances that visitation center should be aware of with respect to the children such as allergies, fears, special needs, etc? Current Foster/ Relative Placement #1 Child(ren) Placed in This Home: Placement Name(s): Placement Type: County: Address: City/ State: Phone: Relation: If placement is a relative or biological parent, please answer the following: DOB: Last 4 digits of SSN: Ethnicity: Marital Status: Highest grade or level completed: Household Income Sources (check all that apply): Estimated Household Income Full-time employment Part-time employment Food Stamps Child Support Private disability insurance Relative Subsidy Retirement Social Security SSI TANF Unemployment VA – Veteran’s Admin WIC Workman’s Comp Other Less than $10,000 $10,000 - $19,999 $20,000 - $29,999 $30,000 - $39,999 $40,000 - $49,999 More than $50,000 If more than one Foster/ Relative Placement #2 Child(ren) Placed in This Home: Placement Name(s): Placement Type: County: Address: City/ State: Phone: Relation: If placement is a relative or biological parent, please answer the following: DOB: Last 4 digits of SSN: Ethnicity: Marital Status: Highest grade or level completed: Household Income Sources (check all that apply): Estimated Household Income Full-time employment Part-time employment Food Stamps Child Support Private disability insurance Relative Subsidy Retirement Social Security SSI TANF Unemployment VA – Veteran’s Admin WIC Workman’s Comp Other Less than $10,000 $10,000 - $19,999 $20,000 - $29,999 $30,000 - $39,999 $40,000 - $49,999 More than $50,000 If more than two Foster/ Relative Placements #3 Child(ren) Placed in This Home: Placement Name(s): Placement Type: County:
2018_family_time_dfcs_referral.docx