The child has a goal to return home and is leaving your home by 7H1l64p


									                              Circuit 10 Provider Input Form
                              Child(ren)’s Name(s):                                             _______

Foster Parent(s)’ Name(s):

To:     Foster Parents/Shelter Parents/Relative Caretaker:

Please complete this form. It is important that we have your input in casework decisions regarding
children placed in your care. This form will be filed in the child’s case file and with the court. Please
complete the following questions if the circumstances in question A or B applies to a child in your home.
If you do not wish to comment, please indicate so on the signature portion of the form and sign.

A.      Reunification:

        The child has a goal to return home and is leaving your home, but the Department is not, at this
        point, going to court on this case; or

B.      Court Review:

        The child is in your home and a court review has been scheduled for

        The Department is recommending

1. How long has this child(ren) resided in your home, and how have they adjusted?

2. What services has this child(ren) received? What services do they need and why?

3. How often have you had home visits by the child’s foster care counselor?

4. What goals do you feel should be established for this child for the next 6 months?

5. Are there any immediate needs of this child?

6. Describe the type and frequency of your contacts with the birth parents:

Please sign and return this form to your Department of Children & Families counselor. If additional
space is needed for your comments, please attach them on additional pages. Thank you for your time and
effort in completing this form.
Provider Input Form
Page 2

 Form Completed By                                 I/We do not wish to comment at this time.

(Foster/Shelter Parent or Relative Caretaker Signature)                         Date

Receipt Acknowledged By:

Family Services Counselor                                                       Date

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