Confidential Reference Request
DD Child Foster Home
Children with Developmental Disabilities
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 foster home
provider for Children with Developmental Disabilities. 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 developmental disabilities fitting into this home?
THIS FORM IS AVAILABLE IN ALTERNATE FORMAT UPON REQUEST
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SDS 4513 (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 ability to meet the mental, physical and emotional
needs of children with developmental disabilities in foster care?
Yes
No
Please explain:
8) Could you please give us an example of when the applicant has shown respect to persons
with differing values, lifestyles, philosophies and/or cultural identity and heritage?
9) How does the applicant react in crisis situation?
THIS FORM IS AVAILABLE IN ALTERNATE FORMAT UPON REQUEST
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10) From your observations, what type of discipline techniques does this applicant use
with children?
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 (i.e., extravagant, understanding,
realistic, etc.)?
12) What experience and/or skills do you know the applicant to have in working with
physically or mentally challenged children?
13) Do you think the applicant would be a good foster parent?
Please explain:
Signature
Yes
No
Date
* Contact information: DHS/SPD may have additional questions regarding your reference:
Phone:
Email:
THIS FORM IS AVAILABLE IN ALTERNATE FORMAT UPON REQUEST
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SDS 4513 (10/11)