General Application for Potential Providers

Personal Information
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Other Last Names Used
Last Names Comma Separated
Email
Enter Email Confirm Email
How were you referred or how did you find out about Circles of Care:*
Are you interested in:
Maiden Name
Address*
Street Address Address Line 2 City State ZIP Code
County*
Home Phone*
Work Phone
Other Phone
Who is your cell phone provider:*
- ATT
- Sprint
- TMobile
- Verizon
How long have you lived at the above address?*
TX Drivers License #*
Gender
Citizenship Status
Marital Status:*
- Married
- Divorced
- Separated
- Single
Ethnicity:*
- Hispanic
- African American
- Caucasian
- Native American
Religion*
- Catholic
- Lutheran
- Protestant
- Jewish
- Baptist
If applicable, name of church/religious institution:

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Members of the Household:
(Include other adults, borders, children, etc.)
Please give Name, Relationship, DOB, Age, Sex, and Occupation for all members of the household.*
Family Members not Living in the Home:
(Grown Children) State standards require references be sent to adult children or contacted.
Please give Name, Relationship, DOB, Age, Address, Phone Number, and Email Address for all members not living in the home.
In Case of Emergency, Please Notify:
Name*
First Last
Phone*
Relationship*

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Education Background:
High School- Name, Location, Dates, Graduate/Year?
College/University- Name, Location, Dates, Graduate/Year?
Vocational School- Name, Location, Dates, Graduate/Year?
Other Education:
Employment History: (last 10 years)
Dates, Employer, City/State, Position, Salary, Reason for Leaving*
Military Service: Branch, Rank, Dates of Service, Type of Discharge

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Medical Background:
Please describe all major and minor health problems.*
Are you or any household members being treated for a physical or psychological illness?*
- Yes
- No
If yes, please explain:
Are you on any medication?*
- Yes
- No
If yes, please give Name, Amount/How often, For:
*******Please note that TB tests are required by each family member for your home to be licensed.

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Criminal History:
Have you or your spouse or any family member living in your home ever been arrested?*
- No
- Yes
If yes, please explain:
Have you or your spouse/ or family member living in your home ever been a subject of a report which addresses the serious physical, emotional, sexual abuse or neglect of a child?*
- No
- Yes
If yes, please explain- Give Dates and circumstances:
Have any of your children ever been involved with juvenile court?*
- No
- Yes
If yes, please explain:
Note: A background check will be completed on the applicants and any household member 14 years of age and older as well as frequent visitors to the home. Frequent is defined as more than twice in a 30-day period.

The following may preclude any person from being a foster parent, being a household member in the foster home or being a frequent visitor in the foster home; Any misdemeanor or felony such as, offenses against a person, robbery, public indecency, stalking, solicitation of a minor, failure to stop or report aggravated sexual assault of a child, making a firearm accessible to a child, intoxication offenses, any felony and any deferred adjudication of any of the above.

Any other charges a person may have will be evaluated and assessed if we will allow licensure; some of the factors used in our assessment include the type of charge, the length of time since the charge, and the age of the applicant at the time of the charge.

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Residence History (Past 10 Years)
Full Physical Addresses are Required
10-Year Residence History*
For the previous 10 years, please list all previous addresses including dates of residence (month and year) and the reason for the move. Write "N/A" if there is no residence change within the last 10 years.
Local and Community Resources:
In what school district do you reside?*
What school would a foster child attend? Give addresses and phone numbers:
Elementary:*
Middle/Junior High:*
High School:*
Other Spec. School:*
What medical facilities are located where you live? How far are they?*
Please list other community resources in the area ( e.g. library, boy/girl scouts, YMCA. Movies, skating):

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Special Skills and Interests:
Foreign Languages/Flunency:
Interests and Hobbies:
Social Activities you participate in:
Professional organizations you belong to:
Volunteer work you have done:

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Emergency Contacts
In the event that the caregiver(s) is unable to provide care to a child in the home; Circles of Care is requesting emergency contact information for any family or friends that would be willing to step in and assist with caregiver responsibilities.
Emergency Contact #1
Name*
Email*
Address*
Phone*
Relationship*
Willing to get Background Check*
- Yes
- No
Emergency Contact #2
Name*
Email*
Address*
Phone*
Relationship*
Willing to get Background Check*
- Yes
- No
Emergency Contact #3
Name
Email
Address
Phone
Relationship
Willing to get Background Check
- Yes
- No
Emergency Contact #4
Name
Email
Address
Phone
Relationship
Willing to get Background Check
- Yes
- No

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General Questions:
Why do you want to become a foster care provider?*
What do you feel you and your family can offer a foster child living in your home?*
Give a brief description of your own childhood, including where you lived, how you were disciplined, how your family communicated, etc.*
Has any member of your family been in foster care or provided foster care?*
- No
- Yes
If yes, who/how long?
If you yourself have provided foster care before or are currently foster parents please give information regarding which agencies you were licensed with and the dates you were licensed with them.
How would you handle the financial situation if your foster care reimbursement check failed to arrive when expected/Do you have other reliable income?*
What methods of discipline do you think are appropriate for children?*
Describe any experience you have in working with children who have emotional, physical, or behavioral problems and what you have learned from that experience:*
Have you ever taken anyone into your home for an extended period of time? If so, please explain:*
Describe a typical week for you, including what you do in your spare time:*
Describe your use of alcohol and /or drugs ( i.e. frequency and amount of use):*
How do you deal with your frustration and anger towards other people, in particular, children and adolescents:*
How do you respond to being supervised by another person?*
How do you believe supervision could help you?*
How would your lifestyle change with a foster child in your home?*
What do you think would make a child:
Runaway?*
Hurt him/herself or someone else?*
Damage Property?*
Have a tantrum?*
What could you do to prevent some of the above situations?*

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Subjective Questions:
My family raised me to value:
A:*
B:*
C:*
My three greatest strengths are:
A:*
B:*
C:*
My three greatest weaknesses are:
A:*
B:*
C:*
The worst part of my adolescence was:*
I expect a child in my care to:*
I can tell when I am burned out when:*
I want to learn more about:*

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References:
**Full names and addresses with zip code must be provided**
Family Member:
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Non-Family Members (2)
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Employer/Co-worker:
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
******Full Address with ZIP CODE must be included*****

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Provider Signature*

By entering your name, you are signing the above form and verifying that all information is correct.
Date*
Month
Day
Year
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This is the final page of the application. Your application has not been submitted yet. Please read the information on this page and fill out the signature fields at the bottom. Then click on "Submit" and wait for the confirmation message to appear. If you do not see a confirmation message, contact Circles of Care for assistance.

Right of Refusal to Deny Licensure & Fee Reimbursement Policy Acknowledgement

Circles of Care reserves the right to deny licensure of foster care or adoption applicants at any time during the licensing process.

Foster and Adoptive Parents who apply with Circles of Care apply as potential providers to be licensed by Circles of Care. The licensing procedure is a “process” that involves many steps and has many requirements. Some of the steps include an FBI check, home study, training, background check and home inspections. Every step and requirement is an opportunity for Circles of Care to evaluate the applicants to determine if the applicants are a good fit for our agency and can meet the needs of the children we serve. Circles of Care reserves the right to deny potential foster and adoption applicants at any time during the licensing process.

Circles of Care is not responsible for any lost work or wages for the time or effort the applicant spends to go through the licensing process, regardless of whether or not the licensure occurs.

In addition, as part of the licensing process, there are certain requirements to include: FBI background checks, Fire Inspections, Health Inspections and TB testing that incur a cost to the applicants. Circles of Care reimburses up to a certain amount for inspection fees and TB testing. The reimbursement amount Circles of Care will pay can change from year to year based on budgets. Applicants need to inquire and know the current reimbursement for these costs and factor that into their decision to pursue licensure.

Applicants are not to schedule or obtain these requirements that have associated fees, unless specifically instructed to do so by Circles of Care. The reimbursement amounts provided by Circles of Care will only be paid to the applicant if Circles of Care had specifically instructed the applicants to obtain these requirements.

No supplies or repairs that may be required to pass such inspections are paid for by Circles of Care nor reimbursed to the applicant regardless of whether or not the applicant is licensed.

Fire and Health Inspections Acknowledgment

As part of the assessment to license a potential foster home, all homes must receive fire and health inspections from the county health department and the city or state fire departments. Once licensed, these inspections are required to be repeated every two (2) years for regular homes and for group homes, once every year.

Circles of Care will reimburse homes for some of the cost of the inspections. Inspection fees range by city and county and the amount Circles of Care will reimburse can change based on budgets. Please inquire about what the current inspection fee reimbursement is and factor that in to your decision to purse licensure. For new potential homes, this reimbursement is done after the home is officially licensed or denied and for current homes, once the inspection reports have been turned in to Circles of Care.

Circles of Care reimburses for the inspection fee cost only. Circles of Care does not pay or reimburse for anything that is required to be done to your home to pass these inspections such as having fire alarms, fire extinguisher or repair and maintenance that the inspectors feel is needed on your home.

Common things needed to pass inspections:

For Fire:
Fire Extinguisher
Fire Alarms on each floor if 2 story
Carbon Monoxide detector if home is equipped with gas
A/C unit serviced or checked out by AC Company

For Health:
First Aid kit
Child cover protectors on electrical outlets
Applicant Signature*

By entering your name, you are signing the above form and verifying that all information is correct. If you are in a two-parent household, a separate application needs to be submitted by both parents.
If you are in a two-parent household, a separate application needs to be submitted by both parents.

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General Application for Potential Providers

General Application for Potential Providers

Step 1 of 14

Personal Information

Description of Current Residence/Home Environment:

Motor Vehicle Information:

Members of the Household:

Family Members not Living in the Home:

Education Background:

Employment History: (last 10 years)

Medical Background:

Criminal History:

Residence History (Past 10 Years)

Local and Community Resources:

Special Skills and Interests:

Emergency Contacts

Emergency Contact #1

Emergency Contact #2

Emergency Contact #3

Emergency Contact #4

General Questions:

Subjective Questions:

References:

Circles of Care- Behavior Tolerance Checklist

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Right of Refusal to Deny Licensure & Fee Reimbursement Policy Acknowledgement

Fire and Health Inspections Acknowledgment