Parent Therapist Application Form






  • Were you referred by anyone in our company?


Identifying Information

Husband






















  • Ever been fired from an employment position?

Husband - Family Background

















  • Has either parent:


Brothers & Sisters

AgeSexMarital Status# of ChildrenOccupation
1.
2.
3.
4.
5.
  • Has any member of your family been convicted of a criminal offence? (The possession of a criminal record will not prevent consideration of this application.)

  • Is any member of your family presently under a Doctor's care for mental health issues?

Wife






















  • Ever been fired from an employment position?

Wife - Family Background

















  • Has either parent:


Brothers & Sisters

AgeSexMarital Status# of ChildrenOccupation
1.
2.
3.
4.
5.
  • Has any member of your family been convicted of a criminal offence? (The possession of a criminal record will not prevent consideration of this application.)

  • Is any member of your family presently under a Doctor's care for mental health issues?

Relationship of Applicant(s)




  • Any children from this relationship?
  • If so, please include their names and ages.
AgeName
1.
2.
3.
4.

  • Previous marriages for either partner?


Current Living Accommodations

  • Type of Accomodation (check one):
  • If house, are you:

  • Are there schools nearby?

  • Are there parks or recreation areas near your house?

  • Any safety concerns around your house?

Financial Situation

Annual Employment Income






  • Life Insurance?

  • Medical Insurance?

  • Car Insurance?

General Information

Please list reasons for wanting to be a Parent/Therapist.

Husband

  • Have you applied before or elsewhere for a foster child

Wife

  • Have you applied before or elsewhere for a foster child

  • Are there any restrictions on the type of the children you are willing to care for?
  • Any preferred age group for children placed in your home?

References

Four references are required for employment with Quinte Children's Homes. Please write the name of a family member, two individuals willing to provide personal references and a form will be provided for your family physician to complete regarding your medical health.

Husband





Wife





Quinte Children's Homes mission is to provide a range of treatment services to children and youth who would benefit from an environment that encourages growth, change and positive interaction in the family, community and within the rights and responsibilities of each individual, by offering programs that develop occupational skills, academic skills, life skills, mutual respect and morality.

The distinctive component of therapeutic foster care is the development and use of Parent/Therapists to provide substitute family life experiences, together with treatment services for the child in a home environment.

Clinical treatment plans to address issues of care through the period of placement are essential for the formulation, evaluation and appropriate modifications. Quinte Children's Homes will provide the treatment services required as well as defining and reviewing goals on a regular basis.

As the applicant(s), the above statements have been read and in making application to receive children into our care in accordance with the terms of a Parent/Therapist Service Agreement to be signed with Quinte Children's Homes Limited, if we are approved to become such a resource. As the applicant(s), I/we understand that the provided information in this application will be given to the Clinician employment by Quinte Children's Homes for the completion of a formal Home Study and will be held in strict confidence. Any information provided in the application will not be released to any individual or agency outside of Quinte Children's Homes without written consent from the applicant(s).

The foregoing information is true and complete to the best of our knowledge. We understand that a false statement could disqualify our application.