MISSOURI DEPARTMENT OF SOCIAL SERVICES
CHILDREN’S DIVISION
PERSONAL REFERENCE QUESTIONNAIRE
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MO 886-0531 (8-04) DISTRIBUTION: WHITE - REFERENCE CANARY - CASE RECORD CS-101F (R8-04)
FROM
TO
¨¨
RE
FAMILY DEVELOPMENT SPECIALIST TELEPHONE NUMBER DATE
AGENCY
ADDRESS CITY STATE ZIP CODE
MISSOURI
CIRCUIT MANAGER/AGENCY DIRECTOR OFFICE HOURS MONDAY-FRIDAY
IF YOU HAVE QUESTIONS
OR NEED ASSISTANCE IN
COMPLETING THIS FORM, PLEASE
CALL THE FAMILY
DEVELOPMENT SPECIALIST
LISTED ABOVE.
REFERENCE NAME
ADDRESS (STREET AND NUMBER)
CITY STATE ZIP CODE
APPLICANTS
Please complete the information below in as much detail as possible and attach a separate sheet if necessary.
1. HOW LONG HAVE YOU KNOWN THIS COUPLE/PERSON? 2. IN WHAT WAY HAVE YOU KNOWN THEM? (SOCIALLY, NEIGHBOR,
BUSINESS, ETC.)
3. THEIR REPUTATION IN THEIR COMMUNITY IS: (PLEASE EXPLAIN ANY NEGATIVE ANSWER)
SUPERIOR ABOVE AVERAGE AVERAGE BELOW AVERAGE POOR
4. WHAT PAST EXPERIENCE HAVE THEY HAD WITH CHILDREN (THEIR OWN OR OTHERS)?
5. WHAT TYPE OF CARE ARE THEY GIVING CHILDREN NOW IN THEIR HOME?
6. ARE YOU FAMILIAR WITH THEIR METHOD OF DISCIPLINING?
YES NO
CAN YOU DESCRIBE THEIR METHODS?
7. PLEASE DESCRIBE THEIR MARITAL RELATIONSHIP (EXPLAIN).
ABOVE AVERAGE AVERAGE BELOW AVERAGE POOR
8. DO YOU KNOW OF ANY PHYSICAL, PSYCHOLOGICAL, OR BEHAVIORAL PROBLEMS WHICH MIGHT INTERFERE WITH THEIR BEING SUCCESSFUL
FOSTER/RELATIVE/ADOPTIVE PARENTS? PLEASE INCLUDE COMMENTS ABOUT THEIR USE OF ALCOHOL, DRUGS, TIME, MONEY; EXTREME
NERVOUSNESS, TEMPER; OR OTHER THINGS YOU THINK IMPORTANT.
DO YOU FEEL THAT THEY WOULD BE ABLE TO:
1. Protect and nurture children in their home? YES NO
2. Meet children’s developmental needs and address developmental delays? YES NO
3. Support relations between children and their families? YES NO
4. Connect children to safe, nurturing relationships intended to last lifetime? YES NO
5. Work as a member of a professional team? YES NO
REFERENCE’S SIGNATURE DATE OCCUPATION
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REFERENCE’S SIGNATURE DATE OCCUPATION
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