Form CFS506-I "Initial Foster Home Licensing Assessment" - Illinois

Form CFS506-I is a Illinois Department of Children and Family Services form also known as the "Form Cfs506-i "initial Foster Home Licensing Assessment" - Illinois". The latest edition of the form was released in December 1, 2014 and is available for digital filing.

Download a PDF version of the Form CFS506-I down below or find it on Illinois Department of Children and Family Services Forms website.

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Download Form CFS506-I "Initial Foster Home Licensing Assessment" - Illinois

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CFS 506-I
State of Illinois
Rev 12/2014
Department of Children and Family Services
INITIAL FOSTER HOME LICENSING ASSESSMENT
FAMILY NAME:
DATE:
PROVIDER ID#:
I. TYPE OF ASSESSMENT:
Initial
Related Only
Adopt Only
New Entity
Interstate Compact ID#:
Requesting State:
Contact Dates:
Supervising Agency:
Agency Address:
Licensing Worker:
Licensing
Worker’s Phone:
Fax:
Licensing Supervisor:
APPLICANT A
APPLICANT B
Name (Last, First)
Name (Last, First)
Date of Birth:
Date of Birth:
Place of Birth
Place of Birth
:
:
Race/Ethnicity/Nationality:
Race/Ethnicity/Nationality:
Home address:
Home phone
:
(including area code)
Cellular Phone
:
Cellular Phone
:
(including area code)
(including area code)
Email Address (optional):
Email Address (optional):
Page 1 of 16
CFS 506-I
State of Illinois
Rev 12/2014
Department of Children and Family Services
INITIAL FOSTER HOME LICENSING ASSESSMENT
FAMILY NAME:
DATE:
PROVIDER ID#:
I. TYPE OF ASSESSMENT:
Initial
Related Only
Adopt Only
New Entity
Interstate Compact ID#:
Requesting State:
Contact Dates:
Supervising Agency:
Agency Address:
Licensing Worker:
Licensing
Worker’s Phone:
Fax:
Licensing Supervisor:
APPLICANT A
APPLICANT B
Name (Last, First)
Name (Last, First)
Date of Birth:
Date of Birth:
Place of Birth
Place of Birth
:
:
Race/Ethnicity/Nationality:
Race/Ethnicity/Nationality:
Home address:
Home phone
:
(including area code)
Cellular Phone
:
Cellular Phone
:
(including area code)
(including area code)
Email Address (optional):
Email Address (optional):
Page 1 of 16
II. INDIVIDUALS RESIDING IN THE HOME:
(Add additional Information on another sheet as needed)
RELATIONSHIP TO
APPLICANT
RESIDES
(Biological, step, foster,
(Check Box)
adopted child, related, or
DATE
other, i.e., grandparent,
NAME
OF BIRTH
Part-Time
Full-Time
friend, etc.)
1.
2.
3.
4.
5.
6.
7.
8.
III. HOME DESCRIPTION (Check all that apply):
Arrangement:
Rent
Own
Other
How long has the applicant resided in their current residence?
Construction:
Single Family
One Level
Two or More Levels
Apartment Building
Condominium
Town Home
Duplex
Mobile Home
Other
Outdoor Space:
Porch
Deck
Patio
Balcony
Fenced Yard
Play Equipment
Shed/Barn
Pool / Hot tub
Pond / Lake / Waterway
Handicapped Accessible
Indoor Space:
Basement
Attic
Number of Bedrooms
Handicapped Accessible
Page 2 of 16
(* Indicate where foster child or children will sleep.)
TYPES OF BEDS
FOR CHILDREN
(Crib, Single, Double,
BEDROOM
NAMES OF OCCUPANTS
Bunk , Trundle,
MEASUREMENTS
FLOOR/LEVEL
(If occupied)
Toddler)
1.
2.
3.
4.
5.
6.
If basement or attic space is approved for sleeping, please describe.
IV. MOTIVATION:
What is the motivation for becoming a foster/adoptive parent? Why is this a good time for the
family to bring children into their home? What adjustments will need to be made if a child is placed in the home?
Page 3 of 16
V. PERSONAL HISTORY OF EACH APPLICANT
:
(Interview each applicant separately)
Family of Origin / Childhood
: Discuss family composition: caregivers, siblings, extended family involvement;
household rules and responsibilities; and activities or routines that are important to the family. What person had a positive
impact on the applicant’s life and why? What statement best captures the applicant’s childhood?
Religion/Values/Beliefs/Culture:
Discuss the role religion/culture played in the applicant’s upbringing. What
values or beliefs were held by the family? Discuss the community in which the applicant was raised in addition to
experiences with different cultures, discrimination, prejudice and the impact.
Emotional and Physical Well-Being
: Does the applicant feel that his/her needs were met? How did the applicant
know he/she was loved? Did anyone in the applicant’s family have medical, mental health or substance abuse issues and
what was the impact? Was there violence in the home? Was there any abuse or neglect in the home? Did the family have
contact with the child welfare system? Criminal system? Who? Why? If the applicant’s childhood experiences were
traumatic, comment on the resolution and whether or not counseling was provided. Comment on how the applicant’s
experiences might support or be a deterrent to fostering/adoption.
Page 4 of 16
Discipline
: How did your caregivers communicate acceptable behavior? How was the applicant taught acceptable /
unacceptable behavior as a child? What behaviors resulted in being disciplined? How were they disciplined? By whom?
Does the applicant feel that discipline was excessive or abusive?
Education
: Discuss level of education attained and the applicant’s attitude about school. What was the expectation
within the applicant’s family regarding education? Does the applicant have any certifications/trainings, that will be useful
in their role as foster parent(s)?
Military History:
Branch served, length of service, type of discharge. Discuss any current or future military
obligations, summarize military experience.
Page 5 of 16
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