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Appendix 1511: Information Needed for the Foster Care Application

CPS September 2004

This tool is used when interviewing the family from which a child has been removed to obtain information for the accurate completion the foster care application.

The tool has two purposes. It prompts the caseworker to gather information about:

  ·  the people in the family and their resources; and

  ·  the child's health insurance coverage.

When interviewing parents to gain the information requested by this instrument, explain that all family information you request is needed to qualify the child for federal benefits and resources that can provide for the needs of the child while in foster care.

Eligibility Questions

Persons in the Household

1.   List:

  ·  each child;

  ·  the child's or children's parents;

  ·  anyone else living in the child's or children's home; and

  ·  each person's relationship to each child.

2.   If the child is (or children are) being physically removed from a relative's home, list:

  ·  the names of all persons living in the home; and

  ·  their relationship to each child.

      Note: If the child is (or children are) being physically removed from a relative, the caseworker affidavit accompanying the court petition must address the situation with the relative indicating why it is contrary to the child's welfare to remain in the relative's home.

Income of Persons in the Household

1.   If there are wage-earners in the household, list:

  ·  the names of people in the child's home who are employed;

  ·  each employed person's relationship to each child; and

  ·  the approximate monthly gross income of each wage earner.

2.   If persons in the household have income from another source, list the:

  ·  names of the person(s) receiving income;

  ·  amount of income;

  ·  type of income; and

  ·  source of income (for example, SSI, RSDI, Child Support, federal, state, or local government benefits, part-time or odd jobs, illegal activities, or other people who live inside or outside the home)

3.   If there is no known income, explain how the family subsists.

a.   How does the family meet its monthly living expenses including housing, food, and clothing?

      This information is entered on the IMPACT foster care application under the "Income/Expenditure" — "Income for Family" Section. A comments box is provided to explain how a family subsists if there is zero income.

b.   Are the bills paid or is money given to the family to assist with the bills?

c.   If financial contributions are provided:

  ·  Approximately how much are the contributions?

  ·  How frequently are the contributions provided (only once monthly, once every two months, etc)?

  ·  Who provides the cash contributions?

Resources

What is estimated value of the family's resources? This includes any property other than their home or car, savings accounts, IRAs, stocks, bonds, land, etc.

If the family owns real property (land or buildings):

  ·  what is the fair market value (estimated at what the property would sell for)?

  ·  what is the assessed value (taxes for property)?

  ·  what is the mortgage balance (amount owed on the property)?

Paternity

1.   Who does the child's mother say is the child's biological father?

2.   Does that person who has been identified as the biological father agree he is the biological father?

3.   Is mother married to someone other than the child's biological father?

4.   Is there a legal determination regarding the biological father's status such as a court order or Acknowledgement of Paternity?

Child's Health Insurance Coverage

1.   If the child has health insurance coverage, document the type of insurance. Obtain the following information:

      Medicaid

  ·  name, address, and phone number for the primary care physician or physician treating the child; and

  ·  policy number, if known, or obtain a copy of the Medicaid card.

      Medicaid Managed Care

  ·  name, address, and phone number of the Primary Care Physician or Physician treating the child; and

  ·  policy number, if known, or obtain a copy of the Medicaid card.

      Children's Health Insurance Program (CHIP)

  ·  name, address, and phone number of the Primary Care Physician or Physician treating child; and

  ·  policy number, if known, or obtain a copy of the CHIP card.

      Private Health Insurance

  ·  name and phone number of the insurance company;

  ·  name, address, and phone number of the primary care physician; and

  ·  policy number and policy owner, if known, or obtain a copy of the insurance card.

2.   If the family does not have any of the above types of health insurance for the child, ask how the family meets the child's medical care needs. If they go to an emergency room or health clinic, document:

  ·  the name of the clinic or hospital, and its address, and phone number

  ·  physician's name, address, and phone number

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