PENNYROYAL CENTER

THERAPEUTIC FOSTER FAMILY PROFILE

NAME (H) _________________________________________________________ SSN __________

NAME (W) _________________________________________________________ SSN ___________

ADDRESS ___________________________________________________________________________

CITY₁ STATE, ZIP ____________________________________________________________________

PHONE NUMBER ____________________________________________________________________

BIRTHDATE (H) ________________________ (W) ______________________

MARITAL STATUS _________________ DATE OF MARRIAGE _____________________

NAME & ADDRESS OF ADULT CHILDREN NO LONGER IN THE HOME:

NAME AND BIRTHDATE OF CHILDREN IN THE HOME:

LIST ANY OTHER HOUSEHOLD MEMBERS (NAME, AGE, AND RELATIONSHIP)

DO YOU OWN or RENT YOUR HOME (CIRCLE ONE)

INSURANCE COMPANY AND COVERAGE ______________________________________________

DESCRIBE YOUR HOME ______________________________________________________________

NUMBER OF BEDROOMS AVAILABLE FOR FOSTER CHILDREN __________________________

SOURCE OF INCOME _________________________________________________________________

EMPLOYMENT HISTORY (Beginning with current job, attach additional sheets if necessary)

HUSBAND EMPLOYMENT:

1. EMPLOYER ___________________________________________________________________________

DATE OF EMPLOYMENT ______________________________________________________________

TYPE OF WORK _______________________________________________________________________

REASON FOR LEAVING _______________________________________________________________

2. EMPLOYER ___________________________________________________________________________

DATE OF EMPLOYMENT ______________________________________________________________

TYPE OF WORK _______________________________________________________________________

REASON FOR LEAVING _______________________________________________________________

9/23/98 PMHC-329