Perpetual Fostering

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Expression of Interest

Applicant Details
Your Name:
Your DOB:
Partner's Name:
Partner's DOB:
Address:
Contact Number:
Email Address:
SOURCE:	Radio
	Newspaper
	Internet & Web
	Leaflet
	Word of Mouth
	OTHER
If "OTHER" please give details:

1. Are you in a relationship? YES / NO
if so for how long?

2. Does anyone in your household smoke? YES / NO

3. Are you and your partner currently employed? (Give details)


4. Have you previously applied to foster? YES / NO
Are you currently approved as a foster carer? YES / NO

5. Do you have a spare bedroom for a foster child?
	One spare room
	2 spare rooms
	More than 2 spare rooms

6. Children/young people requiring foster placements with Independent fostering agencies tend to be aged 10 plus.
Please indicate that you are aware of this?	YES / NO
Are you happy to take this age group?	YES / NO / NOT SURE
Are there any concerns expressed?

7. Do you have any young or adult children living at home? YES / NO If yes - give details:


8. Physical and mental health of the applicants.
A) Are you or your partner on any regular medication?

B) Has anyone in your household been treated for or suffered any significant mental health or depression problems? if so please give details:


9. Has anyone in the household had any involvement with social services in regards to yours or anyone else’s children? YES / NO
if yes – give details :


10. Does anyone in your household have any criminal convictions? YES / NO
If YES give details:


11. Please give details why you wish to become a foster carer.


12. Do you hold a full driving license. YES / NO