Parent Therapist Application Form Date of Application: Name of Applicant(s): Address of Applicant(s): Telephone: E-mail: Were you referred by anyone in our company? YesNoIf yes, please state their name: How did you hear about us i.e. newspaper, friend, web etc.? Identifying InformationHusbandFull Name (as on Birth Certificate): Date of Birth: Place of Birth: Cultural Heritage: Religion: Languages Spoken: Height: Weight: Historical Medical Issues: Current Medical Issues: Historical Mental Health Issues: Current Mental Health Issues: Highest Level of Formal Education: Year Completed: Additional Courses: Formal Training: Volunteer Experiences: Interests & Hobbies: Present Employer: Length of Employment: Relative Employment Experiences: Ever been fired from an employment position? YesNoIf yes, please state details. Husband - Family BackgroundName of Father: Date of Father's Birth: Highest level of education completed: Occupations: Any medical/mental health issues? Description of Personality (Brief): Personal Strengths: Personal Weaknesses Name of Mother: Date of Mother's Birth: Highest level of education completed: Occupations: Any medical/mental health issues? Description of Personality (Brief): Personal Strengths: Personal Weaknesses: Has either parent: DiedDivorcedRemarriedIf so, which parent and when? Comments, if any: Brothers & SistersAgeSexMarital Status# of ChildrenOccupation1.2.3.4.5.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.) YesNoIf yes, please give details: Is any member of your family presently under a Doctor's care for mental health issues? YesNoIf yes, please give details: WifeFull Name (as on Birth Certificate): Date of Birth: Place of Birth: Cultural Heritage: Religion: Languages Spoken: Height: Weight: Historical Medical Issues: Current Medical Issues: Historical Mental Health Issues: Current Mental Health Issues: Highest Level of Formal Education: Year Completed: Additional Courses: Formal Training: Volunteer Experiences: Interests & Hobbies: Present Employer: Length of Employment: Relative Employment Experiences: Ever been fired from an employment position? YesNoIf yes, please state details. Wife - Family BackgroundName of Father: Date of Father's Birth: Highest level of education completed: Occupations: Any medical/mental health issues? Description of Personality (Brief): Personal Strengths: Personal Weaknesses Name of Mother: Date of Mother's Birth: Highest level of education completed: Occupations: Any medical/mental health issues? Description of Personality (Brief): Personal Strengths: Personal Weaknesses: Has either parent: DiedDivorcedRemarriedIf so, which parent and when? Comments, if any: Brothers & SistersAgeSexMarital Status# of ChildrenOccupation1.2.3.4.5.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.) YesNoIf yes, please give details: Is any member of your family presently under a Doctor's care for mental health issues? YesNoIf yes, please give details: Relationship of Applicant(s)Is the current relationship a marriage, girlfriend/boyfriend relationship? Length of Relationship: Any significant separations? Any children from this relationship? YesNoIf so, please include their names and ages.AgeName1.2.3.4.Are there any other individuals that reside in the family home? Previous marriages for either partner? YesNoIf yes, date of divorce. Any children from previous marriages and/or relationships? Current Living AccommodationsType of Accomodation (check one): HouseApartmentDuplexIf house, are you: OwnerTenantNumber of Bedrooms Are there schools nearby? YesNoIf yes, name of school: Are there parks or recreation areas near your house? YesNoIf yes, name them: Any safety concerns around your house? YesNoIf yes, please explain: Financial SituationAnnual Employment IncomeHusband: Wife: Any Additional Income? Please list assets: Please list debts: Life Insurance? YesNoIf yes, amount: Medical Insurance? YesNoIf yes, amount: Car Insurance? YesNoIf yes, amount: General InformationPlease list reasons for wanting to be a Parent/Therapist.HusbandHave you applied before or elsewhere for a foster child YesNoIf yes, where and when? WifeHave you applied before or elsewhere for a foster child YesNoIf yes, where and when? 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? ReferencesFour 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.HusbandFamily Member Personal Personal Name of Physician WifeFamily Member Personal Personal Name of Physician 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.Date: Signature of Applicant: Signature of Applicant: Δ