Candidate’s Name

First

Last

gave your name to BrookeRidge Farms to contact as a reference. They are applying to be licensed as a Foster Home for adults and children with disabilities. Please answer the following questions to help us assess this family’s interpersonal skills and their ability to care for adults and children with disabilities.

Reference Name

First

Last

Reference Email

Reference Phone

Relationship to Candidate

Length of Time Known

Is the person you are providing the reference for applying to be a Host Home Parent (fostering) or Staff?

Host Home Parent
Staff

This will affect what questions need to be answered on this form

How long have you known the applicants, and in what capacity?

Have you ever been in the family’s home? How often, and under what circumstances?

Describe the family relationships in the home. How do family members relate to each other

Describe how the applicants relate to others in the community.

Describe the discipline the applicants use for their own children and any concerns you might have.

Indicate your observations regarding the physical or mental health of the applicants.

Are you aware of any drug or alcohol related problems the applicants, or any member of their family/household may have? Please explain.

Are you aware of incidents of child abuse or neglect in connection with the applicants, or any members of their family/household? Please explain.

Do you feel this family can provide appropriate care to children or adults with disabilities? If not please explain.

Do you have any further comments you wish to make regarding the applicant’s character or personality?

Strengths of the Candidate

Areas for Improvement

Reliability/Dependability

Interpersonal Skills

Adaptability/Flexibility

Communication Skills

Leadership Abilities

Punctuality/Attendance

the long of

Any Red Flags or Concerns?

Additional Comments

Reference Letter

address

Office working hours