HG Screening Form - Gulf Coast JFCS

Pre-Screening Form

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Applicant Information

Applicant 1(Required)

First Last

Applicant 2

First Last

Your Email Address(Required)

Email Address Confirm Email Address

Pre-screening - Characteristics Checklist

This is a characteristics checklist for placement matching with children in our registry. Please answer these questions as honestly as possible.

Gender/Sex of Child

MALE(Required)

Preferred

Acceptable

Would Consider

Unacceptable

FEMALE(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Race/Ethnicity/Culture of Child

A child of the SAME racial/ethnic/cultural background as that of the family(Required)

Preferred

Acceptable

Would Consider

Unacceptable

A child of a DIFFERENT racial/ethnic/cultural background as that of the family(Required)

Preferred

Acceptable

Would Consider

Unacceptable

A child of ANY racial/ethnic/cultural background(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Number/Type of Children

ONE (1) child(Required)

Preferred

Acceptable

Would Consider

Unacceptable

TWO (2) children(Required)

Preferred

Acceptable

Would Consider

Unacceptable

THREE (3) children(Required)

Preferred

Acceptable

Would Consider

Unacceptable

FOUR (4+) or more children(Required)

Preferred

Acceptable

Would Consider

Unacceptable

TEEN Parent with CHILD(Required)

Preferred

Acceptable

Would Consider

Unacceptable

SIBLINGS(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Age of Child

0-2 Years of Age(Required)

Preferred

Acceptable

Would Consider

Unacceptable

3-5 Years of Age(Required)

Preferred

Acceptable

Would Consider

Unacceptable

6-8 Years of Age(Required)

Preferred

Acceptable

Would Consider

Unacceptable

9-11 Years of Age(Required)

Preferred

Acceptable

Would Consider

Unacceptable

12 Years or OLDER(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Health of Child

No Significant Health Problems(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Allergies or Asthma (May Require Treatment)(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Hyperactivity (May Require Treatment)(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Speech Problems (May Require Treatment)(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Hearing Problems (May Require Treatment)(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Legally Deaf(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Vision Problems (May Require Treatment)(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Legally Blind(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Dental Problems (May Require Treatment)(Required)

Preferred

Acceptable

Would Consider

Unacceptable

High Achiever(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Seizure Disorder (May Require Treatment)(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Other Medical Condition that May Require Treatment(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Education of Child

High Achiever(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Achieving AT Grade Level(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Achieving BELOW Grade Level(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Needs Special Education(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Needs Emotional Handicapped Education(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Needs Tutoring in One or More Subjects(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Has Serious Behavior Problems at School(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Characteristics and Behavior of Child

Generally Quiet and Shy(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Generally Outgoing and Noisy(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Has Emotional Issues Requiring Therapy at Present(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Has Tendency to Reject Father Figures(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Has Tendency to Reject Mother Figures(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Tends to Form Mostly Superficial Relationships(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Has Difficulty Making Friends and Relating with Other Children(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Frequently Wets Bed(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Has Tendency to Reject Frequently Wets During the Day Figures(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Frequently Soils Him/Herself(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Masturbates Frequently and/or Openly(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Has Poor Social Skills(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Has A Problem with Lying(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Has A Problem with Stealing(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Frequent Physical Altercations with Other Children(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Tends to Abuse Animals(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Tends to Be Destructive of Personal Property(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Frequently Uses Language You Would Consider Inappropriate(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Has Frequent Temper Tantrums(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Has Difficulty Accepting and Obeying Rules(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Has A History of Inappropriate Sexual Behavior(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Has Sexual Identity and/or Trans-Gender Issues(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Has A History of Running Away(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Has a History of Setting Fires(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Has A History of self harm(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Family History

Has Strong Ties to Birth Family(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Has Strong Ties to Foster Family(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Will Need Continued Contact with Siblings in Adoptive Placement(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Has Had a Previous Adoption Disruption(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Has Been Sexually Abused(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Has Been Physically Abused(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Has Been Exposed to Promiscuous Behavior(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Was Conceived as A Result of Rape(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Was Conceived as a Result of Prostitution(Required)

Preferred

Acceptable

Would Consider

Unacceptable

One or Both Biological Parents Has Alcohol Addiction(Required)

Preferred

Acceptable

Would Consider

Unacceptable

One or Both Biological Parents Has Drug Dependency(Required)

Preferred

Acceptable

Would Consider

Unacceptable

One or Both Biological Parents Has A Criminal Record(Required)

Preferred

Acceptable

Would Consider

Unacceptable

One or Both Biological Parents Is/Are Mentally Handicapped(Required)

Preferred

Acceptable

Would Consider

Unacceptable

One or Both Biological Parents Has A Mental Illness(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Agency Has No Information on One or Both Biological Parents(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Adoptive Family's Feelings Towards Openness

Is Willing to Meet Birth Parents(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Is Willing to Have Contact with Birth Parents Through Intermediary(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Is Willing to Send Correspondence to Birth Parents(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Is Willing to Receive Correspondence from Birth Parents(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Is Willing to Have Child Continue Visitation with Siblings(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Is Willing to Have Child Continue Visitation with Extended Relatives(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Is Willing to Have Child Continue Visitation with Birth Parents(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Is Willing to Receive Demographic Information About Birth Parents(Required)

Preferred

Acceptable

Would Consider

Unacceptable

Is Willing to Distribute Demographic Information to Birth Parents(Required)

Preferred

Acceptable

Would Consider

Unacceptable

ISSUES

I/We am/are willing to consider a child with the following issues: (Please check the highest level that will be considered)

MENTAL HEALTH

ADD/ADHD

Mild

Moderate

Severe

Will NOT consider

Depression

Mild

Moderate

Severe

Will NOT consider

Bi-polar Disorder

Mild

Moderate

Severe

Will NOT consider

Schizophrenia

Mild

Moderate

Severe

Will NOT consider

Reactive Attachment Disorder

Mild

Moderate

Severe

Will NOT consider

Other mental health diagnoses

Mild

Moderate

Severe

Will NOT consider

History of psychiatric hospitalizations

Mild

Moderate

Severe

Will NOT consider

History of therapeutic foster care

Mild

Moderate

Severe

Will NOT consider

Drug/Alcohol problems

Mild

Moderate

Severe

Will NOT consider

BEHAVIORAL

Tantrums

Mild

Moderate

Severe

Will NOT consider

Property destruction

Mild

Moderate

Severe

Will NOT consider

Physical aggression with peers and adults

Mild

Moderate

Severe

Will NOT consider

Fire Setting

Mild

Moderate

Severe

Will NOT consider

History of sexual abuse

Mild

Moderate

Severe

Will NOT consider

Sexually acting out

Mild

Moderate

Severe

Will NOT consider

Masturbation

Mild

Moderate

Severe

Will NOT consider

Perpetration

Mild

Moderate

Severe

Will NOT consider

Promiscuity (sexualized behaviors)

Mild

Moderate

Severe

Will NOT consider

Sexually Transmitted Disease

Mild

Moderate

Severe

Will NOT consider

Behavioral concerns/issues

Mild

Moderate

Severe

Will NOT consider

Truancy

Mild

Moderate

Severe

Will NOT consider

DJJ History

Department of Juvenile Justice

Mild

Moderate

Severe

Will NOT consider

Conduct Disorder

Mild

Moderate

Severe

Will NOT consider

Oppositional Defiant Disorder

Mild

Moderate

Severe

Will NOT consider

Other behavior disorder

Mild

Moderate

Severe

Will NOT consider

DEVELOPMENTAL/ COGNITIVE

Mild Developmental Disability (MR) [IQ 60-69]

Mild

Will NOT consider

Moderate/Profound Developmental Disability [IQ below 60]

Mild

Moderate

Severe

Will NOT consider

Down Syndrome

Mild

Moderate

Severe

Will NOT consider

Autism Spectrum Disorder

Mild

Moderate

Severe

Will NOT consider

Learning Disability

Mild

Moderate

Severe

Will NOT consider

Speech/Motor/Communication

Mild

Moderate

Severe

Will NOT consider

MEDICAL

Cerebral Palsy

Mild

Moderate

Severe

Will NOT consider

Deaf/ hearing difficulties

Mild

Moderate

Severe

Will NOT consider

Blind

Mild

Moderate

Severe

Will NOT consider

Non-ambulatory [wheelchair bound]

Mild

Moderate

Severe

Will NOT consider

Scoliosis

Mild

Moderate

Severe

Will NOT consider

Enuresis/Encopresis

Urinating/Soiling themselves

Mild

Moderate

Severe

Will NOT consider

Feeding problems (G-Tube)

Mild

Moderate

Severe

Will NOT consider

Diabetes

Mild

Moderate

Severe

Will NOT consider

Sleep disorders

Mild

Moderate

Severe

Will NOT consider

Asthma

Mild

Moderate

Severe

Will NOT consider

HIV positive

Mild

Moderate

Severe

Will NOT consider

HIV exposed

Mild

Moderate

Severe

Will NOT consider

Other blood disorder

Mild

Moderate

Severe

Will NOT consider

Heart defects/problems

Mild

Moderate

Severe

Will NOT consider

Physical malformations

Mild

Moderate

Severe

Will NOT consider

Glasses/visual problems

Mild

Moderate

Severe

Will NOT consider

Speech problems

Mild

Moderate

Severe

Will NOT consider

Spina Bifida

Mild

Moderate

Severe

Will NOT consider

Cleft Lip

Mild

Moderate

Severe

Will NOT consider

Hereditary/Genetic disorder, which may not appear until late childhood or adulthood

Mild

Moderate

Severe

Will NOT consider

Fetal alcohol syndrome

Mild

Moderate

Severe

Will NOT consider

History of drug/alcohol exposure/addiction at birth

Mild

Moderate

Severe

Will NOT consider

Thank You

We recognize the pre-screen took some time, and we appreciate you.

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Name

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Melanie Hoffman

Kelly Jordan

Anthony Saccento

Pre-Screening Form

Applicant Information

Pre-screening - Characteristics Checklist

Adoptive Family's Feelings Towards Openness

ISSUES

Thank You

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