Texas Department of Family
and Protective Services
Form 0398
September 2011
KINSHIP PROFILE QUESTIONNAIRE
INSTRUCTIONS: Complete as much of this form as possible. If you have problems completing this form, please contact
the worker who sent this form to you for assistance. If a question does not apply to you, write N/A (Non-Applicable).
CAREGIVER #1:
Full Legal Name:
(First)
(Middle)
(Last)
Any other names you have used:
Birthdate
Birthplace
Height
Weight
Hair Color
Eye Color
Race/Ethnicity
Military Record:
Branch of Service
Dates of Service
Highest Rank Obtained
Type of Discharge
Work Performed in Service
Criminal Record:
Have you ever been convicted
Yes
No
If yes, give the nature of the charges and disposition
of charges
Education:
Highest school grade completed
When completed?
Where completed
College years completed
Degree
List any special training you have received and where it was received
EMPLOYMENT:
Current employer
Address
Type of Work Performed
Position
Phone No.
Starting Date
Texas Department of Family
and Protective Services
Form 0398
September 2011
Previous employment for last 5 years if different from present employment
(If needed, use back of page)
Employer’s Name
Position
Address
Phone No.
Starting Date
Ending Date
Reason For Leaving
Hobbies:
Previous Marriages (If none, so state):
Full Name of Spouse
Date of Marriage
Place of Marriage
Date of Divorce
or Death of Spouse
Number of
Children
Divorce Decree No. (if available)
or County Where Divorced
Child Support:
Name(s) of Child(ren)
Do you visit your children?
If No, why?
Yes
Amount of Child
Support Payment
No
Automatic
Deduction by
Employer
If Yes, how often?
Is Payment
Current?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Texas Department of Family
and Protective Services
Form 0398
September 2011
MEDICAL HISTORY:
Have you had a history of or treatment for any of the following?
No
Yes
No
Yes
No
Tuberculosis
Depression
Alcoholism
Cancer
Seizures
Asthma
Severe Arthritis
Heart Condition
Chronic Headaches
Chronic Kidney
Condition
Mental/Emotional Problems
Chronic Fatigue
Colitis
Ulcers
Insomnia
Eczema
Hemophilia
Allergies
Hay fever
Diabetes
Other:
Have you ever received treatment for a mental illness?
No
Yes
Yes
If so, when and who gave treatment:
Have you taken medication for mental or emotional problems?
No
Yes
When:
Drug(s) Prescribed:
Have you ever intentionally hurt yourself or attempted to commit suicide?
No
Yes
If so, when and why?
____________________________________________________________________________________________________________________
Have you ever gone to counseling for emotional or family problems?
No
Yes
If so, when and who was the counselor?
_____________________________________________________________________________________________________________________
Have you ever had a psychological examination or battery of psychological tests?
No
Yes
If so, when did you receive the psychological exam, and what was your diagnosis?
If you are an adult, are you physically able to have children?
No
Yes
If no, why not?
_____________________________________________________________________________________________________________________
Texas Department of Family
and Protective Services
Form 0398
September 2011
List all admissions to the hospital
Date
Place
Reason for Admission
List all prescription medications being taken on a regular basis.
Medication
Reason for Medication
Date of last visit to doctor and reason:
List all illnesses you have had in the past year:
Do you have a physical disability?
No
Yes
If yes, please explain
_____________________________________________________________________________________________________________________
Have you ever been treated for drug usage?
No
Yes
If yes, when and where?
Have you ever been treated for alcoholism?
No
Yes
If yes, when and where?
A statement may be needed from a physician, psychologist, or counselor concerning you and /or your child's past or
current physical, mental or emotional condition. Are you willing to give permission for release of such information, if
necessary?
No
Yes
CAREGIVER #2:
Full Legal Name:
(First)
(Middle)
(Last)
Texas Department of Family
and Protective Services
Form 0398
September 2011
Any other names you have used:
Birth Date
Birthplace
Height
Weight
Hair Color
Eye Color
Race/Ethnicity
Military Record:
Branch of Service
Dates of Service
Highest Rank Obtained
Type of Discharge
Work Performed in Service
Criminal Record:
Have you ever been convicted
Yes
No
If yes, give the nature of the charges and disposition
of charges
Education:
Highest school grade completed
When completed?
Where completed
College years completed
Degree
List any special training you have received and where it was received
EMPLOYMENT:
Current employer
Address
Type of Work Performed
Position
Phone No.
Starting Date
Texas Department of Family
and Protective Services
Form 0398
September 2011
Previous employment for last 5 years if different from present employment
(If needed, use back of page for additional employment history)
Employer’s Name
Position
Address
Phone No.
Starting Date
Ending Date
Reason For Leaving
Hobbies:
Previous Marriages (If none, so state):
Full Name of Spouse
Date of Marriage
Place of Marriage
Date of Divorce
or Death of Spouse
Number of
Children
Divorce Decree No. (if available)
or County Where Divorced
Child Support:
Name(s) of Child(ren)
Do you visit your children?
Yes
Amount of Child
Support Payment
No
Automatic
Deduction by
Employer
If Yes, how often?
Is Payment
Current?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Texas Department of Family
and Protective Services
Form 0398
September 2011
If No, why?
MEDICAL HISTORY:
Have you had a history of or treatment for any of the following?
No
Yes
No
Yes
No
Tuberculosis
Depression
Alcoholism
Cancer
Seizures
Asthma
Severe Arthritis
Heart Condition
Chronic Headaches
Chronic Kidney
Condition
Mental/Emotional Problems
Chronic Fatigue
Colitis
Ulcers
Insomnia
Eczema
Hemophilia
Allergies
Hayfever
Diabetes
Other:
Have you ever received treatment for a mental illness?
No
Yes
Yes
If so, when and who gave treatment:
Have you taken medication for mental or emotional problems?
No
Yes
When:
Drug(s) Prescribed:
Have you ever intentionally hurt yourself or attempted to commit suicide?
No
Yes
If so, when and why?
____________________________________________________________________________________________________________________
Have you ever gone to counseling for emotional or family problems?
No
Yes
If so, when and who was the counselor?
_____________________________________________________________________________________________________________________
Have you ever had a psychological examination or battery of psychological tests?
No
Yes
If so, when did you receive the psychological exam, and what was your diagnosis?
If you are adult, are you physically able to have children?
No
Yes
If no, why not?
_____________________________________________________________________________________________________________________
List all admissions to the hospital
Date
Place
Reason for Admission
Texas Department of Family
and Protective Services
Form 0398
September 2011
List all prescription medications being taken on a regular basis.
Medication
Reason for Medication
Date of last visit to doctor and reason:
List all illnesses you have had in the past year:
Do you have a physical disability?
No
Yes
If yes, please explain
_____________________________________________________________________________________________________________________
Have you ever been treated for drug usage?
No
Yes
If yes, when and where?
Have you ever been treated for alcoholism?
No
Yes
If yes, when and where?
A statement may be needed from a physician, psychologist, or counselor concerning you and /or your child's past or
current physical, mental or emotional condition. Are you willing to give permission for release of such information, if
necessary?
No
Yes
PRESENT HOUSEHOLD:
Address
Phone No.
How long have you lived at this address?
Is this address a:
How many rooms do you have?
House
Mobile Home
How many bedrooms?
Apartment
How many baths?
Texas Department of Family
and Protective Services
Form 0398
September 2011
CHILDREN CURRENTLY LIVING IN THE HOME:
Name
Birth Date
Relationship
Grade/School
CHILD CARE ARRANGEMENTS:
When both parents are working or away from home, who cares for the children?
Name / Facility Name
Are the children current on their immunizations?
Age of Caregiver
(If not a Facility)
No
Phone Number
Yes
If not, why?
______________________________________________________________________________________________
Texas Department of Family
and Protective Services
Form 0398
September 2011
MONTHLY BUDGET:
INCOME
GROSS
TAKE HOME
Husband’s Monthly Income ..............................................
Wife’s Monthly Income ....................................................
Other Monthly Income (Child Support, Rent, etc.) ....................
TOTAL INCOME ...........................................................
MONTHLY EXPENSES
House Payment (Rent/Mortgage) ........................................................................
Payments on Other Real Property .......................................................................
Automobile Payment ...........................................................................................
Automobile Expenses (Gas/Upkeep) ..................................................................
Food ....................................................................................................................
Utilities (Electricity, gas, water, etc.) ..................................................................
Telephone Expenses ............................................................................................
Revolving Charge Accounts (Visa, Sears, etc.) ..................................................
Insurance .............................................................................................................
Life ..........................................................................................................
Health/Hospitalization .............................................................................
Auto .........................................................................................................
Property ...................................................................................................
Medical/Dental Expenses ....................................................................................
Clothing ...............................................................................................................
Furniture ..............................................................................................................
Church Contributions ..........................................................................................
Entertainment ......................................................................................................
Support of Relatives ............................................................................................
Miscellaneous (Specify) ......................................................................................
TOTAL MONTHLY EXPENSES ...................................................................
AMOUNT
OWED
Texas Department of Family
and Protective Services
Form 0398
September 2011
PEOPLE WHOM WE CAN TALK TO THAT KNOW YOU WELL:
1.
Name
Address
Relationship
2.
Day Phone No.
Night Phone No.
Name
Address
Relationship
3.
Day Phone No.
Night Phone No.
Name
Address
Relationship
4.
Day Phone No.
Night Phone No.
Name
Address
Relationship
5.
Day Phone No.
Night Phone No.
Name
Address
Relationship
6.
Day Phone No.
Night Phone No.
Name
Address
Relationship
Day Phone No.
Do you have firearms in the home?
Night Phone No.
Yes
No
If yes, what type of gun(s) and where/how stored:
Texas Department of Family
and Protective Services
Form 0398
September 2011
COMMENTS (any additional information you feel will be helpful):
WE AFFIRM THAT THE ANSWERS WE HAVE PROVIDED ARE ACCURATE TO THE BEST
OF OUR KNOWLEDGE.
Signature
Date
Signature
Date