Employer Gross Annual Income Sources of Additional Income MARITAL / DOMESTIC PARTNER / CIVIL UNION INFORMATION Date of Current Marriage / Domestic Partnership / Civil Union PAST MARRIAGE(S) / DOMESTIC PARTNERSHIP(S) / CIVIL UNION(S) Applicant 1 Full Name Date Begun Date Ended [Name of Past Spouse / Partner] [Name of Past Spouse / Partner] Applicant 2 Full Name Date Begun Date Ended [Name of Past Spouse / Partner] [Name of Past Spouse / Partner] DATES OF CONTACT Date Person(s) Interviewed Length of Interview (Hours and Minutes) Location SONS AND DAUGHTERS OF APPLICANT(S) Name Birthdate Age DOD, if Deceased Location and Living Situation (Adult children must be interviewed. Provide contact information if not living in the home. Include date of death if deceased.) Receiving Care In Home Out of Home Yes No In Home Out of Home Yes No In Home Out of Home Yes No In Home Out of Home Yes No In Home Out of Home Yes No In Home Out of Home Yes No In Home Out of Home Yes No In Home Out of Home Yes No In Home Out of Home Yes No In Home Out of Home Yes No OTHERS RESIDING OR FREQUENTLY IN THE HOME (INCLUDING OTHER PERSONS RECEIVING CARE) Foster children placed in the home or children placed in the pre-adoptive home are not included here. The definition of adults frequently in the home is any adult who is in the home on a regular basis and has substantial contact with children placed in the home or any adult who while in the home would have access to be alone with children placed in the home. Name Age Relationship Current Situation Receiving Care Yes
I affirm that the factual statements in the home study are true and correct to the best of my knowledge and the home study recommendation was arrived at with professional due diligence and judgment. Wisconsin. I this home study and certify that this is a true and accurate copy. SIGNATURE – Home Study Practitioner Date Signed SIGNATURE – Supervisor Date Signed Name – Home Study Practitioner Name – Supervisor Title Title RECEIPT OF COPY OF HOME STUDY REPORT By signing below I acknowledge receiving a copy of this report and affirm that the factual statements in this home study are true and correct to the best of my knowledge. SIGNATURES Name – Applicant 1 SIGNATURE – Applicant 1 Date Signed Name – Applicant 2 SIGNATURE – Applicant 2 Date Signed PSYCHOSOCIAL INVENTORY RESULTS #1 #2 Applicant #1: Applicant Full Name #1 #2 Applicant #2: Applicant Full Name HISTORY EXTENDED FAMILY RELATIONSHIPS Childhood Family Adaptability Extended Family Cohesion Childhood Family Cohesion Extended Family Adaptability Childhood History of Deprivation / Trauma Relationship with own Extended Family Child History of Victimization Relationship with Spouse’s / Partner’s Family Adult History of Victimization / Trauma PHYSICAL / SOCIAL ENVIRONMENT History of Child Abuse / Neglect Cleanliness / Orderliness / Maintenance History of Alcohol / Drug Use Safety Crime / Arrest / Allegations / Violence Furnishings Psychiatric History Play Area / Equipment / Clothing Occupational History Finances Marriage / Domestic Partner / Civil Union History Support System PERSONAL CHARACTERISTICS Household Pets Communication GENERAL PARENTING Commitment and Responsibility Child Development Problem Solving Parenting Style Interpersonal Relations Disciplinary Methods Health and Physical Stamina Child Supervision Self-esteem Learning Experiences Acceptance of Differences Parental Role Coping Skills Child Interactions