TFC PRE-SCREENING FORM

THERAPEUTIC FOSTER CARE TO ADOPT AND ADOPTION PRE-SCREENING TOOL

Please fill out the following form
in order to participate in our activity.

First Name:

Last Name:

Spouse's Full Name:

Date:

Address:

Mailing Address (if different):

County Reside In:

Cell Phone Number:

How did you hear about SCSCY TFC/Adopt Care Service?

Marital Status:

Number of children in the home, ages, sex:

Name/Age:

Date of Birth:

Social Security #:

Name/Age:

Date of Birth:

Social Security #:

If a CPS transfer family:

Name of CPS worker (whom we can contact for information such as training certificates, CPR/First Aid Certification, Physical, TB skin test and home study):

CPS worker's Phone number (if you have it):

Name of person completing pre-screen tool:

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!