No Yes No Yes No Yes No Yes No EXTENDED FAMILY MEMBERS: Applicant 1 Full Name Name Age DOD, if Deceased Relationship Frequency of Contact Location Source of Supportive Relationship Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No EXTENDED FAMILY MEMBERS: Applicant 2 Full Name Name Age DOD, if Deceased Relationship Frequency of Contact Location Source of Supportive Relationship Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No REFERENCES Name Relationship to Applicant(s) Date Received MEDICAL / SCHOOL REPORTS Medical Reports Health evaluation from pertaining to completed on: Health evaluation from pertaining to completed on: Health evaluation from pertaining to completed on: Health evaluation from pertaining to completed on:
REMEMBER: Sustaining: If an issue / behavior or event is not resolved and you are sustaining the Desk Guide Rating, please indicate how it affects the Applicants’ current functioning, ability to parent and how it would or does affect children in the home. Reducing: If an issue / behavior or event is partially resolved and you are reducing the Desk Guide Rating, please provide evidence that indicates how the issue / behavior or event was reduced, how it would or does affect current functioning, ability to parent, and how it would or does affect children in the home. Erasing: If you believe that an issue/behavior or event no longer affects the Applicants and you are erasing the SAFE Desk Guide Rating, please provide evidence to support your assessment that the issue/behavior or event no longer affects the Applicants’ current functioning or ability to parent. Never reference numbers or ratings in your narration. PSYCHOSOCIAL EVALUATION REPORT HISTORY: Applicant 1 Full Name Historical Information Evaluation HISTORY: Applicant 2 Full Name Historical Information Evaluation PERSONAL CHARACTERISTICS: Applicant 1 Full Name Evaluation If the Applicant is taking any medications (prescribed or over-the-counter), please list and indicate the medical reasons for which they are being taken. PERSONAL CHARACTERISTICS: Applicant 2 Full Name Evaluation If the Applicant is taking any medications (prescribed or over-the-counter), please list and indicate the medical reasons for which they are being taken. MARITAL / DOMESTIC PARTNER / CIVIL UNION RELATIONSHIP Evaluation Provide a brief description of the Applicant(s)’s Marriage / Domestic Partnership / Civil Union highlighting their roles in the relationship, division of duties, strengths, and skills.
GENERAL PARENTING Evaluation How was / were the Applicant(s) disciplined as a child and how does that impact the way he / she / they discipline(s) his / her / their children and / or will discipline any future children? What kind of discipline does / do the Applicant(s) intend to use? Does / Do the Applicant(s) have good knowledge of appropriate and effective forms of discipline? Parental Style: SPECIALIZED PARENTING Family Preparation and Training Activities Evaluation ADOPTION / FOSTER CARE ISSUES Maintaining Connections with Birth Families Evaluation PSYCHOSOCIAL EVALUATION CONCLUSIONS PLACEMENT CONSIDERATIONS Future Placement Considerations Child Specific Placement Considerations RECOMMENDATION It is recommended that and be for . Based on my review of this home study report and the recommendation cited above, the Applicant(s) is / are for . Home Study Practitioner Supervisor I certify that I am authorized by the laws of the state of Wisconsin to prepare home studies by virtue of my status or employment with 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. This home study was prepared in accordance with the requirements that apply to foster care and adoption in the state of 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