Confidential Reference Request
DD Child Foster Home
Children with Developmental Disabilities
Serving Children with Significant Medical Needs
To: {first and last name}
{address line one}
{address line two}
{city/state/zip}
An application has been filed with the Department of Human Services (DHS) and Seniors and
People with Disabilities (SPD) by
to be a child foster home
provider for developmentally disabled children with significant medical needs. You have been
listed as a reference. We would appreciate your complete responses to the questions below. If
you need additional room for answers, please attach additional pages.
Your answers will be held in strict confidence.
Thank you for assisting us in objectively considering this applicant for parenting a foster child
with developmental disabilities. We would appreciate it if you could return this questionnaire as
soon as possible to the address listed below.
Address of County DD Program
Foster care certifier
If you have any questions or need assistance in completing this form, please call:
at
Name
Phone number
1) What is your current occupation?
2) How long have you known the applicant?
3) What is your relationship to the applicant?
4) How do you see children with disabilities fitting into this home?
THIS FORM IS AVAILABLE IN ALTERNATE FORMAT UPON REQUEST
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SDS 4513M (10/11)
5) From your observations, how does the applicant get along with and relate to children?
6) Do you think the applicant is responsible , stable and emotionally mature?
Please give examples:
Yes
No
7) Do you think the applicant has the capacity to meet the mental, physical, emotional and
significant medical needs of children with developmental disabilities in foster care?
Yes
No (“Significant medical needs” means, but is not limited to, total assistance
required for all activities of daily living such as access to food or fluids, daily hygiene,
which is not attributable to the child’s chronological age and frequent medical
interventions required by the care plan for health and safety of the child.)
Please explain:
8) Could you please give us an example of when the applicant has shown respect to persons
with different values, lifestyles, philosophies and/or cultural identity and heritage?
9) From your observations, how does the applicant react to a medical emergency?
THIS FORM IS AVAILABLE IN ALTERNATE FORMAT UPON REQUEST
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10) What experience and/or skills do you know the applicant to have in working with children
with significant medical care needs?
11) Do you know of any characteristics this applicant may have, both positive and negative,
which may affect his or her ability to rear a child with significant medical care needs?
12) Do you have any recommendations for additional medical training for the applicant?
13) Additional comments:
Signature
THIS FORM IS AVAILABLE IN ALTERNATE FORMAT UPON REQUEST
Date
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