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Section 1 of 8
YouthNet Services Prospective Parent Questionnaire
Thank you for your interest in becoming a prospective parent with YouthNet Services.  There is such a great need to help children, youth and adults in Utah States custody.  If you have made it to this point we hope that you will follow through with the process to make a difference in the lives of those who need it most….
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Name of Applicant #1
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Name of applicant #2
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Address
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City
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State
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Zip Code
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Phone Number
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Email 
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How did you hear about us
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Social Media
Google
Referral
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Are you interested in:
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Foster Parent
Proctor Parent
Host Home Parent
Professional Parent
Transition to Adult Living Parent (Youth 16-21 apartment like setting)
All of the above
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Brief description of why you are interested in working with children, youth and adults in care?
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Section 2 of 8
Marital Information
Department of Health and Human Services does not require you to be married to be a foster parent.  However, if you are living with a significant other you are required to be legally married to be a foster parent.  You can be a single individual 21 years of age to apply.
If you are living with someone, are you legally married and can provide a marriage certificate?
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Yes
No
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Marital Status
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Married
Single
Divorced
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Questions or concerns about marriage requirements
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Section 3 of 8
Age Requirement
You must be 21 years or older to be a parent
Are you 21 years or older
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Yes
No
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Section 4 of 8
Supervision Requirement
I understand that supervision is required  for individuals in care
I understand that individuals in my care must be supervised in some way at all times.
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No
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There will always be someone home  to supervise children in my care
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Comments or concerns about supervision 
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Section 5 of 8
Home Information
Tell us about your home.
What time of dwelling to you reside in?
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1.
House
2.
Town home
3.
Apartment
4.
Trailer Home
5.
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Do you have an extra room for individuals in your home immediatety?
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Yes
No
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Do you have 3 or less children residing in your home
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Yes
No
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If yes list ages
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Are you able to support yourself without the financial assistance from those you will care for?
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No
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Are you willing to provide proof of income?
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No
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Section 6 of 8
Information about children and youth placed in your home
Children and youth placed in your home may have major behavioral and mental issues.  Many have experienced trauma from sexual, emotional & physical abuse.  
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I Understand
I did not know
I understand but I am still willing to explore becoming a foster parent.
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Section 7 of 8
Personal Information
I Understand that everyone 12 years of age and older are required to pass a background check.
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No
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How many people in your household will require a background check?
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Is there any criminal history that we should be aware of?
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No
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Do you have a valid Drivers License?
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No
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Do you have a personal vehicle?
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Do you travel out of the state or country often?
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No
Other:
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Do you have first aid and cpr certification 
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No
Other:
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Section 8 of 8
Are you ready to move forward?
When would you like to start
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ASAP
2 WEEKS
1 MONTH
2 MONTHS
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What is stopping you from starting right away?
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How would you like to be contacted for the next step
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Phone
Email
I think I’m not ready
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Who will be the point of contact
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Name of Applicant #1
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Name of applicant #2
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Address
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Email 
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How did you hear about us
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Are you interested in:
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Brief description of why you are interested in working with children, youth and adults in care?
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Marital Information
If you are living with someone, are you legally married and can provide a marriage certificate?
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Marital Status
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Questions or concerns about marriage requirements
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Age Requirement
Are you 21 years or older
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Supervision Requirement
I understand that individuals in my care must be supervised in some way at all times.
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There will always be someone home  to supervise children in my care
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No responses yet for this question.
Comments or concerns about supervision 
No responses yet for this question.
Home Information
What time of dwelling to you reside in?
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No responses yet for this question.
Do you have an extra room for individuals in your home immediatety?
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No responses yet for this question.
Do you have 3 or less children residing in your home
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No responses yet for this question.
If yes list ages
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Are you able to support yourself without the financial assistance from those you will care for?
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No responses yet for this question.
Are you willing to provide proof of income?
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No responses yet for this question.
Information about children and youth placed in your home
Children and youth placed in your home may have major behavioral and mental issues.  Many have experienced trauma from sexual, emotional & physical abuse.  
Copy chart
No responses yet for this question.
Personal Information
I Understand that everyone 12 years of age and older are required to pass a background check.
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No responses yet for this question.
How many people in your household will require a background check?
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No responses yet for this question.
Is there any criminal history that we should be aware of?
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No responses yet for this question.
Do you have a valid Drivers License?
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No responses yet for this question.
Do you have a personal vehicle?
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No responses yet for this question.
Do you travel out of the state or country often?
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No responses yet for this question.
Do you have first aid and cpr certification 
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No responses yet for this question.
Are you ready to move forward?
When would you like to start
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No responses yet for this question.
What is stopping you from starting right away?
No responses yet for this question.
How would you like to be contacted for the next step
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Who will be the point of contact
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No responses yet for this question.
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