Home Study Templete

SAFE Home Study
Home study was completed by: Name of Caseworker/Evaluator

Name of Agency
Number and Street
City, State, ZIP Code
Name of Family:
Family Address:
Family Home Phone:
>> APPLICANT DISPOSITION

Application received on: Home study completed on:
FUTURE PLACEMENT
The Applicants applied to become an Adoptive Family placement of a male or female child between the ages of
Age and Age from the country of at time of referral.
The Applicants Select One open to the placement of a sibling group. If open to a sibling group,
how many?
The family is open to the following medical needs:
CHILD SPECIFIC PLACEMENT

The Applicants applied to become Select One for Name(s), birthdate(s).
>> APPLICANT INFORMATION

Applicant 1 Full Name Applicant 2 Full Name
Maiden Name (if applicable): Maiden Name (if applicable):
Date of Birth: Date of Birth:
Mobile Phone: Mobile Phone:
Work Phone: Work Phone:
E-Mail Address: E-Mail Address:
Birthplace: Birthplace:
Sex: Sex:
Height: Height:
Weight: Weight:
Hair: Hair:
Eye Color: Eye Color:
Religion: Religion:
Consortium for Children, 2013 all rights reserved-Structured Analysis Family Evaluation, International Home Study Template 09-05-2015 1
SAFE Home Study
Race: Race:
Ethnic Origin: Ethnic Origin:
Tribal Affiliation: Tribal Affiliation:
Education: Education:
Citizenship (what country?): Citizenship (what country?):
Alien Registration Number (if required): Alien Registration Number (if required):
Language(s): Language(s):
Occupation: Occupation:
Employer: Employer:
Annual Gross Income: Annual Gross Income:
Sources of Additional Income: Sources of Additional Income:
>> MARITAL/DOMESTIC PARTNER RELATIONSHIP

Date of Current Marital/Domestic Partner Relationship:
PAST MARRIAGE(S)/DOMESTIC PARTNER RELATIONSHIP(S)

Applicant 1 Full Name Date Begun Date Ended
[--Name of Past Spouse/Partner--]
Applicant 2 Full Name Date Begun Date Ended

>> DATES OF FACE-TO-FACE CONTACTS

Person(s) Interviewed Length of Interview Location
(Hours and Minutes)
>> SONS AND DAUGHTERS OF APPLICANTS

Name Age Location
(Adult children should be interviewed. Provide contact information if not
living in the home. Include date of death if deceased)
SAFE Home Study
>> OTHERS RESIDING OR FREQUENTLY IN THE HOME

Name Age Relationship Current Situation
>> EXTENDED FAMILY MEMBERS: Applicant 1 Full Name

Include Applicants birth parents, adoptive parents, step parents, siblings and other prominent extended family
members (living or deceased)
Name Relationship Location and Living Situation
>> EXTENDED FAMILY MEMBERS: Applicant 2 Full Name

Include Applicants birth parents, adoptive parents, step parents, siblings and other prominent extended family
members (living or deceased)
Name Relationship Location and Living Situation
>> REFERENCES
Name Relationship to Applicants Date Received
SAFE Home Study
The references have known Steven and Allison between 5 and 13 years. All three references were positive and
strongly agree that Steven and Allison are capable of providing love and security to any child. Steven is seen as
outgoing, honest, and friendly while Allison is described as active, happy, and compassionate. Both Steven and
Allison are seen as supportive, hardworking, and responsible. The references stated Steven and Allison are in a
strong, loving and stable marriage. One reference stated Steven and Allison have always been respectful,
responsible, and fun with children another reference stated Steven and Allison have lots of experience with
children and are great with them All three references would feel very comfortable allowing Steven and Allison
to care for their children if they were unable to do so.
>> MEDICAL/SCHOOL REPORTS

Medical Reports
Health Evaluation from [--name--] pertaining to Applicant 1 Full Name completed on:
Health Evaluation from [--name--] pertaining to Applicant 2 Full Name completed on:
Health Evaluation from [--name--] pertaining to [--name--] completed on:
Health Evaluation from [--name--] pertaining to [--name--] completed on:
Psychiatric Evaluation Applicant 1 Full Name Yes No
Psychiatric Evaluation Applicant 2 Full Name Yes No
>> APPLICANTS/OTHERS CRIMINAL/CPS RECORDS CHECK

The required criminal record and child abuse/neglect checks were completed for Applicant 1 Full Name and
Applicant 2 Full Name along with any adult(s) living in the Applicants home. Any findings will be elaborated
on in the Psychosocial Evaluation History section of this report.
Applicant 1 Full Name Colorado State Criminal Records Check [--date completed--]
FBI Criminal Records Check [--date completed--]
Colorado Sex Offender Check [--date completed--]
National Sex Offender Check [--date completed--]
Trails/Colorados Child Abuse/Neglect Check [--date completed--]
Applicant 2 Full Name Colorado State Criminal Records Check [--date completed--]
FBI Criminal Records Check [--date completed--]
Colorado Sex Offender Check [--date completed--]
National Sex Offender Check [--date completed--]
Trails/Colorados Child Abuse/Neglect Check [--date completed--]
SAFE Home Study
>> MOTIVATION
FUTURE PLACEMENT FAMILIES

[--State the Applicants stated reasons for wanting to adopt internationally. Specify their country of choice and
why they have chosen this country.--]
[--Indicate whether or not the Applicants have any adoption experience and the response of each adult member of
the household as to whether he/she has ever been approved, rejected or deferred as a prospective adoptive parent, or
has been the subject of an unfavorable home study with any child placing agency.--]
CHILD SPECIFIC FAMILIES

[--Provide the Name(s), DOB, sex, family circumstances and legal status of the child(ren) being considered.--]
[--Physically describe each child/youth involved in the home study: name, sex, age, date of birth, height, weight,
eye, and hair color.--]
[--For each child/youth currently in the home, discuss their adjustment since placement. If not currently placed
with the Applicants discuss the nature and character of the Applicants relationship(s) with the child(ren) or
youth(s).--]
[--Describe the strengths, personality, interests, and emotional/physical development of each child or youth being
considered in the home study.--]
[--Discuss the level of understanding each child/youth has about such issues as reunification, maintaining
connections, adoption, etc. --]
>> SELF STATEMENT OF Applicant 1 Full Name
The Applicant was asked if he/she had ever applied or attempted to adopt before this time or if they have ever been
the subject of an unfavorable home study report or rejected as a potential adoptive parent. The Applicant was also
asked about any history of alcohol or substance abuse, sexual abuse, child abuse, family violence or criminal
history, even if it did not result in an arrest or conviction either as a victim or perpetrator, in the United States or
abroad. The Applicant states that they have no history of these problems and has never been arrested, detained or
convicted of a crime in the United States or abroad. The Applicant was asked if Immigration ever refused them a
VISA clearance and they stated no.
>> SELF STATEMENT OF Applicant 2 Full Name
The Applicant was asked if he/she had ever applied or attempted to adopt before this time or if they have ever been
the subject of an unfavorable home study report or rejected as a potential adoptive parent. The Applicant was also
asked about any history of alcohol or substance abuse, sexual abuse, child abuse, family violence or criminal
history, even if it did not result in an arrest or conviction either as a victim or perpetrator, in the United States or
abroad. The Applicant states that they have no history of these problems and has never been arrested, detained or
convicted of a crime in the United States or abroad. The Applicant was asked if Immigration ever refused them a
VISA clearance and they stated no.
>> HOME AND COMMUNITY
Type of Residence (House, Apartment, Condominium, etc.): [--Enter Here--]

Square footage: [--Enter Here--]
Number of Bedrooms: [--Enter Here--]
Number of Bathrooms: [--Enter Here--]
SAFE Home Study
Length of time in current residence: [--Enter Here--]
[--Describe the home and community so that a reader can picture the home and the surrounding community. This
should be a strength-based description pointing out what makes the home unique to the Applicants (special
decorations, color schemes, projects, etc.) Indicate whether the home meets state requirements. --]
[--Describe the neighborhood as well as the community surrounding the residence and focus on resources in the
area: hospitals/specialized medical providers, schools, special education programs, places of worship, mental health
services, etc.--]
>> APPLICANT PROFILE: Applicant 1 Full Name
[--Describe the Applicants physical appearance: height, weight, hair and eye color, striking physical attributes.
Describe how the Applicant presents himself/herself assured, hesitant, physically active, sedate, thoughtful, etc.
Briefly describe any special interests, hobbies, expertise, or talents the Applicant possesses. Also, describe what
the Applicant shared regarding his/her aspirations and goals in life. You may also include something their
spouse/partner has said about them that describes their personality.--]
>> APPLICANT PROFILE: Applicant 2 Full Name
[--Describe the Applicants physical appearance: height, weight, hair and eye color, striking physical attributes.
Describe how the Applicant presents himself/herself assured, hesitant, physically active, sedate, thoughtful, etc.
Briefly describe any special interests, hobbies, expertise, or talents the Applicant possesses. Also, describe what
the Applicant shared regarding his/her aspirations and goals in life. You may also include something their
spouse/partner has said about them that describes their personality.--]
>> FAMILY LIFESTYLE
[--This is your opportunity to introduce this family to the home study reader.--]
[--Describe typical work and non-work day routines and rituals. Describe how the Applicants feel their routines
and rituals will or have changed with the placement of a child or children.--]
[--What are the basic household rules, roles, and expectations? Who does what in terms of chores, cooking, bill
paying, home maintenance, transportation, etc.? --]
[--Describe what recreational, cultural, social, and/or religious activities the Applicants participate in. --]
[--If the Applicants have pets describe them. Who is responsible for pet care? Who ensures their well-being
(vaccinations, checkups)?--]
CHILD CARE
[--Describe current and proposed childcare arrangements. Who will be or has been designated their substitute
caregiver? What is his/her relationship to the Applicants? What measures have been or will be taken to assure that
substitute caregiver(s) is responsible and sensitive to a childs needs? What are the Applicants short and long-term
emergency substitute childcare plans?--]
PRIVACY
[--Describe the sleeping arrangements and how the family deals with privacy and nudity in the home. Describe
how they have or will modify this behavior with/since the placement of children in the home.--]
>> LEGAL/FINANCIAL RESPONSIBILITIES

SAFE Home Study
The Applicant(s) have been provided with information concerning the different roles, responsibilities, legal and
financial rights and benefits of international adoptive parents.
The agencys complaint procedures [--have/have not--] been explained to the Applicants.
PSYCHOSOCIAL EVALUATION REPORT
>> HISTORY: Applicant 1 Full Name
[-- Provide a one paragraph narrative describing the Applicant's history: where and when they were born, who they
were born to, siblings, schooling, marriages, civil unions, domestic partnerships, deaths, divorces, etc. Do not
include issues you have identified in the Psychosocial Inventory with SAFE Desk Guide Ratings. This is a factual
description of the Applicant's history. --]
Mental Health Reports
Referrals were not made to mental health resources as the practitioners professional assessment that none were
needed based on the Applicants current functioning and the fact that they did not have any significant issues
related to any past history of illness, or any mental, emotional, psychological, or behavioral instability. If mental
health resources.
Special Instructions: If referrals were made to mental health resources please delete the above section and discuss
in the Psychosocial Evaluation (see below).
EVALUATION
[--Follow Evaluation Instructions--]
[--If referrals were made to mental health resources for further mental health evaluation during the home study,
indicate that the evaluation conclusions and specific issues that required further evaluation using Psychosocial
Narration Instructions (page 1)--]
>> PERSONAL CHARACTERISTICS: Applicant 1 Full Name
[--If Applicant is taking any medications (prescribed or over-the-counter), please list and indicate the medical
reasons for which they are being taken.--]
EVALUATION
>> HISTORY: Applicant 2 Full Name
[-- Provide a one paragraph narrative describing the Applicant's history: where and when they were born, who they
were born to, siblings, schooling, marriages, civil unions, domestic partnerships, deaths, divorces, etc. Do not
include issues you have identified in the Psychosocial Inventory with SAFE Desk Guide Ratings. This is a factual
description of the Applicant's history. --]
Mental Health Reports
Referrals were not made to mental health resources as the practitioners professional assessment that none were
needed based on the Applicants current functioning and the fact that they did not have any significant issues
SAFE Home Study
related to any past history of illness, or any mental, emotional, psychological, or behavioral instability. If mental
health resources.
Special Instructions: If referrals were made to mental health resources please delete the above section and discuss
in the Psychosocial Evaluation (see below).
EVALUATION
[--If referrals were made to mental health resources for further mental health evaluation during the home study,
indicate that the evaluation conclusions and specific issues that required further evaluation using Psychosocial
Narration Instructions (page 1)--]
>> PERSONAL CHARACTERISTICS: Applicant 2 Full Name
[--If Applicant is taking any medications (prescribed or over-the-counter), please list and indicate the medical
reasons for which they are being taken.--]
EVALUATION
>> MARITAL/DOMESTIC PARTNERSHIP RELATIONSHIP
[--Provide a brief description of the Applicants Marriage/Domestic Partnership highlighting their roles in the
relationship, division of duties, strengths and skills.--]
EVALUATION
>> SONS/DAUGHTERS/OTHERS RESIDING OR FREQUENTLY IN THE HOME
MINOR SON(S) OR DAUGHTER(S)

[--For each minor son or daughter of the Applicants or either Applicant, provide the minors name, age and sex
followed by a description of their personality, interests, school and living situation.--]
[--Is the minors behavior age-appropriate? Does the minor present any health, developmental, educational or
mental health issues? How secure, well adjusted, and adaptable is the minor? Are his/her needs being well met?
Does the minor exhibit any behaviors that pose a threat to the health, safety, and well-being of self or others? Does
the minor have a secure attachment to both his/her parents? Does the minor have any alcohol or drug involvement?
How prepared is the minor for the arrival of a new child into the family?--]
EVALUATION
OTHER MINORS RESIDING OR FREQUENTLY IN THE HOME

[--Provide the name, age, sex of any other minors residing or frequently in the home. Describe the nature of the
relationship of each minor to the Applicants followed by a description of their personality, interests, school, and
circumstances.--]
[-- Is the minors behavior age-appropriate? Does the minor present any health, developmental, educational or
mental health issues? How secure, well adjusted, and adaptable is the minor? Are his/her needs being well met?
SAFE Home Study
Does the minor exhibit any behaviors that pose a threat to the health, safety, and well-being of self or others? Does
the minor have any alcohol or drug involvement? How prepared is the minor for the arrival of a new child into the
family?--]
EVALUATION
ADULT SON(S) OR DAUGHTER(S)

[--If the Applicants have adult sons or daughters, provide the name, age, sex, marital/domestic partnership/civil
union status, occupation, circumstances and place or residence of any adult son or daughter. Also indicate if they
have children and the type of contact they would have with a child placed.--]
[--How positive and supportive is he/she about having a new child come into the family? How much and how
frequently does he/she consume alcohol? Does he/she use illegal drugs or abuse prescriptive/over-the-counter
drugs? How well does he/she accept differences? Does he/she exhibit responsible behavior and emotional
stability? Does he/she exhibit any behaviors that pose a threat to the health, safety, and well-being of self or
others? Does he/she have a history of criminal arrests, convictions, or allegations of child sexual/physical abuse,
child neglect, child exploitation, or failure to protect?--]
EVALUATION
ADULTS RESIDING OR FREQUENTLY IN THE HOME

[--If there are other adults residing or frequently in the home, provide the name, age, sex and marital/domestic
partnership/civil union status of each adult identified. Indicate each individuals occupation, circumstances, the
nature of his/her relationship with the Applicants and the amount and type of contact he/she would have with a
child placed in the Applicants home.--]
[--How positive and supportive is he/she about having a new child come into the family? How much and how
frequently does he/she consume alcohol? Does he/she use illegal drugs or abuse prescriptive/over-the-counter
drugs? How well does he/she accept differences? Does he/she exhibit responsible behavior and emotional
stability? Does he/she exhibit any behaviors that pose a threat to the health, safety, and well-being of self or
others? Does he/she have a history of criminal arrests, convictions, or allegations of child sexual/physical abuse,
child neglect, child exploitation, or failure to protect?--]
EVALUATION
>> EXTENDED FAMILY RELATIONSHIPS: Applicant 1 Full Name
[--Describe if and how the extended family is positive regarding the Applicants desire to adopt. Has anyone in the
extended family had any experience as an adoptive parents?--]
EVALUATION
>> EXTENDED FAMILY RELATIONSHIPS: Applicant 2 Full Name
[--Describe if and how the extended family is positive regarding the Applicants desire to adopt. Has anyone in the
extended family had any experience as an adoptive parents?--]
EVALUATION
SAFE Home Study
>> PHYSICAL/SOCIAL ENVIRONMENT
[--Finances: [--Place special emphasis on this factor by addressing each of the Desk Guide criteria that apply even
if the Final Desk Guide Rating is a 2. Describe the Applicants; income, financial resources, debts and expenses.
State the evidence that was considered to verify the source and amount of income and financial resources. Is the
family income and financial resources sufficient to meet family needs? Clarify that any income designated for the
support of children in the care and custody of the Applicants or any income used for support of any other member
of the household is not used for purposes of evaluating income and finances. Are the Applicants able to budget,
organize and spend money wisely? Do the Applicants have adequate resources available for emergencies?--]
[--Safety: Provide the information that your regulations, rules and statutes require pertaining to the residence such
as swimming pool/fountains, other water features, guns, trampolines etc. Please provide the Safety Plan if
appropriate. Describe all pets and discuss their comfort level with children. Indicate if anyone in the household
smokes and if so indicate the designated smoking areas --]
EVALUATION
>> GENERAL PARENTING
[--How were the Applicants disciplined as a child and how does that impact the way they discipline their children
and/or will discipline any future children? What kind of discipline do the Applicants intend to use? Do the
Applicants have good knowledge of appropriate and effective forms of discipline?--]
Bring together the ratings of the Applicants and describe how they would parent a child with few or no issues.
EVALUATION
>> SPECIALIZED PARENTING
FAMILY PREPARATION AND TRAINING ACTIVITIES

[--Identify and describe all adoption education activities including pre-service training the Applicants have
participated in. If applicable, indicate how the preparation process addressed issues specific to the special needs of a
child.--]
[--Special Narration Instruction for H-4, Effects of Separation and Loss: Place special emphasis on this factor
by providing full narration that relates to each of the Desk Guide criteria that apply even if the Final Desk Guide
Rating is 2. Your narration needs to expand upon the Applicants ability to address the unique separation and loss
issues inherent in international adoption such as the effects of institutionalization on children, abandonment, lack of
opportunity for pre-placement visits, language barriers and child adjustment challenges.
[--Special Narration Instruction for H-6, Therapeutic and Educational Resources: Place special emphasis on
this factor by providing full narration that relates to each of the Desk Guide criteria that apply even if the Final
Desk Guide Rating is 2. Your narration needs to expand upon the Applicants readiness to address the challenges
inherent in international adoption that result from a lack of medical and social background information and the
heightened risk of developmental delays.
[--Special Narration Instructions for H-10, Cross Cultural Issues: Place special emphasis on this factor by
providing full narration that relates to each of the Desk Guide criteria that apply even if the Final Desk Guide
SAFE Home Study
Rating is 2. Your narration needs to evaluate whether or not the Applicants are ready, willing and able to parent a
child of a different race or culture and ensure that the childs heritage and cultural identity will be honored and
embraced--]
EVALUATION
>> ADOPTION ISSUES
[--Maintaining Connections with Birth Families: Do the Applicants understand and accept the importance of
maintaining birth family connections for a child who has been adopted? Are they secure in their parental role as
adoptive parents and ready, willing and able to support contact with birthparents and other significant connections
such as siblings and grandparents based on the best interest of the child? Are the Applicants willing to be involved
in family visits, family team meetings, and working as a team member to meet the permanency goal for a child?--]
[--Special Narration Instructions for I-4, Adoptive Parent Status: Place special emphasis on this factor by
addressing the following. Summarize the counseling given to prepare the prospective adoptive parents for an
international adoption and any plans for post placement counseling. Verify and record that this pre-adoption
counseling included a discussion of the processing, expenses, difficulties and delays associated with international
adoptions. Verify and record that the Applicants understand the importance of and have agreed to post-placement
and post-adoption reporting requirements as required by their childs state or country. Verify and record the
Applicants agreement and willingness to cooperate with the social worker in the developing these reports. If
applicable, verify that the family is up to date on any current post placement reports for past adoptions. --]
EVALUATION
>> COUNTRY SPECIFIC INFORMATION
Please reference the information sheet on the country in question and include any additional information that the
country might require.
>> PSYCHOSOCIAL EVALUATION CONCLUSIONS
[--Discuss each of the strengths and concerns you have covered earlier in the home study. Please make a
determination how each issue together and separately could or does affect the Applicants current functioning or
ability to parent.--]
>> PLACEMENT CONSIDERATIONS
FUTURE PLACEMENT CONSIDERATIONS

[--Indicate the age range, sex and background of the children or youth that you believe are compatible with this
family. Specify any child/youth special needs, considerations, behaviors, conditions or issues the Applicants are
uniquely qualified to address along with those they are not ready, willing and able to manage or consider.--]
CHILD SPECIFIC PLACEMENT CONSIDERATIONS

[--Discuss each childs or youths goodness of fit with this family and whether or not the Applicants are ready,
willing and able to address each of the childs/youths needs, special considerations and issues as identified on the
SAFE Compatibility Inventory or by other means.--]
>> RECOMMENDATION
SAFE Home Study
It is recommended that the International adoption home study for Applicant 1 Full Name and Applicant 2 Full
Name be Choose an item..
[--If this report is favorable, summarize the reasons for such approval. Include the number of children that the
prospective adoptive parents may adopt. State whether there are any specific restrictions such as nationality, age
or gender of the child. If the prospective parents are approved for a h or special needs adoption, clearly state the
fact.--]
>> ATTESTATION
Home Study Practitioner:
I certify that I am authorized by the laws of the State of [-State-] (Insert Citation to Applicable State law) to
prepare home studies. In accordance with 9CFR 204.311(f) I declare under penalty of perjury under U.S. law that I
personally and with due professional diligence reasonably necessary to protect the best interest of any child whom
the Applicants might adopt, either actually conducted or supervised this home study (interviews, home visits and
other necessary investigations) or if I did not, the following individual did so as indicated below:
[-Name-]
[-Agency-]
[-Agency Address -]
[-Telephone Number-]
[-E-mail Address-]
Nature of Contribution (please describe activities conducted by above named individual):
The factual statements in this home study are true and correct to the best of my knowledge, information and belief.
I have advised the Applicants of their duty of candor under paragraph d of this section, specifically noting the
ongoing duty of disclosure of new events of information, and the consequences should they fail to disclose any
information.
The home study is a true and accurate copy of the home study that was provided to Immigration and has been
reviewed by the Applicants.
This home study was prepared for International adoption in accordance with such standards and in accordance with
the standards and requirements that apply to a domestic adoption in the State of [-State-]. The Applicants actual
State of residence or with those in the Applicants proposed State of residence. I am authorized to conduct
Convention home studies by virtue of my status or employment. My status is: Choose an item.
OR
Prepared by Worker Name, Credentials, who is authorized by the State of [-State-] under the Rules Regulating
Child Placement Agencies to research and prepare home studies and is employed by [-Agency Name and license
number-]. [-Agency Name-] is a supervised provider for [-contracted Hague agency-], based on a signed agreement
executed on [-date of contract between agencies-]. In accordance with 22 CFR Part 96 [-Hague Accredited agency
and license number -] is an accredited agency on file with the United States Department of State as having authority
to conduct Convention home studies.
This home study will be submitted to the designated agency who has the contract authority with the State of [-
State-] to review and approve international home studies completed in [-] by licensed child placement agencies.
Signature Date Signature Date
SAFE Home Study
Name of Home Study Evaluator Name of Authorized Approving Authority

Title Title
>> APPLICANTS REVIEW OF HOME STUDY REPORT

By signing below, I acknowledge that I have read a copy of this home study and affirm that the information I
provided for this report is true and correct to the best of my knowledge.
Applicant 1 Full Name Applicant 2 Full Name
Check for document updates
SAFE Home Study
PSYCHOSOCIAL INVENTORY RESULTS

#1 #2 Applicant #1: Applicant 1 Full Name #1 #2 Applicant #2: Applicant 2 Full Name
HISTORY EXTENDED FAMILY RELATIONSHIPS
2 2 Childhood Family Adaptability 2 2 Extended Family Cohesion
2 2 Childhood Family Cohesion 2 2 Extended Family Adaptability
2 2 Childhood History of Deprivation/Trauma 2 2 Relationship with Own Extended Family
2 2 Childhood History of Victimization 2 2 Relationship with Spouse/Partner Family
2 2 Adult History of Victimization/Trauma PHYSICAL/SOCIAL ENVIRONMENT
2 2 History of Child Abuse/Neglect 2 Cleanliness/Orderliness/Maintenance
2 2 History of Alcohol/Drug Use 2 Safety
2 2 Crime/Arrest/Allegations/Violence 2 Furnishings
2 2 Psychiatric History 2 Play Area/Equipment/Clothing
2 2 Occupational History 2 Finances
2 2 Marriage/Domestic Partner History 2 Support System
PERSONAL CHARACTERISTICS 2 Household Pets
2 2 Communication GENERAL PARENTING
2 2 Commitment and Responsibility 2 2 Child Development
2 2 Problem Solving 2 2 Parenting Style
2 2 Interpersonal Relations 2 2 Disciplinary Methods
2 2 Health and Physical Stamina 2 2 Child Supervision
2 2 Self-esteem 2 2 Learning Experiences
2 2 Acceptance of Differences 2 2 Parental Role
2 2 Coping Skills 2 2 Child Interactions
2 2 Impulse Control 2 2 Communication with Child
2 2 Mood 2 2 Basic Care
2 2 Anger Management and Resolution 2 2 Childs Play
2 2 Judgment SPECIALIZED PARENTING
2 2 Adaptability 2 2 Expectations
MARITAL/DOMESTIC PARTNER RELATIONSHIP 2 2 Effects of Abuse/Neglect
2 Conflict Resolution 2 2 Effects of Sexual Abuse
2 Emotional Support 2 2 Effects of Separation and Loss
2 Attitude toward Spouse 2 2 Structure
2 Communication between Couple 2 2 Therapeutic/Educational Resources
2 Balance of Power 2 2 Birth Sibling Relationships
2 Stability of the Marriage 2 2 Child Background Information
2 Sexual Compatibility 2 2 Birth Parent Issues
2 2 Cross Cultural Issues
SONS/DAUGHTERS/OTHERS RESIDING OR ADOPTION/FOSTER CARE ISSUES
FREQUENTLY IN THE HOME
2 Minor Sons and Daughters 2 2 Infertility
2 Minors Residing or Frequently in the Home 2 2 Telling Child about Adoption
2 Adult Sons and Daughters 2 2 Openness in Adoption
2 Adults Residing or Frequently in the Home 2 2 Adoptive Parent Status
I affirm that each psychosocial factor listed above was considered and rated with due professional diligence on the SAFE
Psychosocial Inventory during the course of this home study. The ratings above represent the Final Desk Guide Ratings
and corresponding Mitigation Ratings for all Final Desk Guide Ratings of 3, 4 or 5.
Name of Home Study Evaluator Name of Home Study Supervisor

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SAFE Home Study

Home study was completed by: Name of Caseworker/Evaluator

>> APPLICANT DISPOSITION

The family is open to the following medical needs:

CHILD SPECIFIC PLACEMENT

>> APPLICANT INFORMATION

>> MARITAL/DOMESTIC PARTNER RELATIONSHIP

PAST MARRIAGE(S)/DOMESTIC PARTNER RELATIONSHIP(S)

Applicant 2 Full Name Date Begun Date Ended

>> DATES OF FACE-TO-FACE CONTACTS

>> SONS AND DAUGHTERS OF APPLICANTS

>> OTHERS RESIDING OR FREQUENTLY IN THE HOME

>> EXTENDED FAMILY MEMBERS: Applicant 1 Full Name

>> EXTENDED FAMILY MEMBERS: Applicant 2 Full Name

>> MEDICAL/SCHOOL REPORTS

Psychiatric Evaluation Applicant 2 Full Name Yes No

>> APPLICANTS/OTHERS CRIMINAL/CPS RECORDS CHECK

FUTURE PLACEMENT FAMILIES

CHILD SPECIFIC FAMILIES

>> SELF STATEMENT OF Applicant 1 Full Name

>> SELF STATEMENT OF Applicant 2 Full Name

>> HOME AND COMMUNITY

Type of Residence (House, Apartment, Condominium, etc.): [--Enter Here--]

Length of time in current residence: [--Enter Here--]

>> APPLICANT PROFILE: Applicant 1 Full Name

>> APPLICANT PROFILE: Applicant 2 Full Name

>> FAMILY LIFESTYLE

>> LEGAL/FINANCIAL RESPONSIBILITIES

PSYCHOSOCIAL EVALUATION REPORT

>> HISTORY: Applicant 1 Full Name

Mental Health Reports

>> PERSONAL CHARACTERISTICS: Applicant 1 Full Name

>> HISTORY: Applicant 2 Full Name

Mental Health Reports

>> PERSONAL CHARACTERISTICS: Applicant 2 Full Name

>> MARITAL/DOMESTIC PARTNERSHIP RELATIONSHIP

>> SONS/DAUGHTERS/OTHERS RESIDING OR FREQUENTLY IN THE HOME

MINOR SON(S) OR DAUGHTER(S)

OTHER MINORS RESIDING OR FREQUENTLY IN THE HOME

ADULT SON(S) OR DAUGHTER(S)

ADULTS RESIDING OR FREQUENTLY IN THE HOME

>> EXTENDED FAMILY RELATIONSHIPS: Applicant 1 Full Name

>> EXTENDED FAMILY RELATIONSHIPS: Applicant 2 Full Name

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>> PHYSICAL/SOCIAL ENVIRONMENT

>> GENERAL PARENTING

>> SPECIALIZED PARENTING

FAMILY PREPARATION AND TRAINING ACTIVITIES

>> ADOPTION ISSUES

>> COUNTRY SPECIFIC INFORMATION

>> PSYCHOSOCIAL EVALUATION CONCLUSIONS

>> PLACEMENT CONSIDERATIONS

FUTURE PLACEMENT CONSIDERATIONS

CHILD SPECIFIC PLACEMENT CONSIDERATIONS

Home Study Practitioner:

Nature of Contribution (please describe activities conducted by above named individual):

Signature Date Signature Date

Name of Home Study Evaluator Name of Authorized Approving Authority

>> APPLICANTS REVIEW OF HOME STUDY REPORT

Applicant 1 Full Name Applicant 2 Full Name

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PSYCHOSOCIAL INVENTORY RESULTS

Signature Date Signature Date