Adoption & Comprehensive Foster Care MAPP Pre-Screening

Street Address (Please note we can only work with families living in Massachusetts)

Name (First and Last)

Street Address (Please note we can only work with families living in Massachusetts)

Age range Select all that apply

0-5 6-12 13-17 18-22

How did you hear about us?

Please answer the following questions. Your answers will be used to determine areas for further discussion

Additional Household Members

HOUSEHOLD INFORMATION

Do you have other household members?

Yes No

Number of Bedrooms

1 2 3 or more

CHILD INTEREST CHARACTERISTICS

Age range (Select all that apply)

0-5 6-12 13-17 18-22

Race/Ethnicity (Select all that apply)

Legal Risk

Low Moderate High

Physical Challenges

Mild Moderate Severe

Behavioral Issues

Mild Moderate Severe

Cognitive Limitations

Mild Moderate Severe

Mental Health History (child or family)

Mild Moderate Severe

Personal Information (please respond for either inquirer as applicable)

Have you ever been legally involved, detained, charged and/or arrested by the police?

Yes No

Have you ever had a negative home study?

Yes No

Have you ever been involved with DCF as an adult/child/reporter?

Yes No

Have you struggled with infertility?

Yes No

Do you currently have any serious medical conditions?

Yes No

Have you had serious medical conditions in the past?

Yes No

Does anyone in your household smoke/vape?

Yes No

Are you prescribed any medications?

Yes No

Does anyone in your household have a history of substance abuse?

Yes No

Does anyone in your household have a history of domestic violence?

Yes No

Has anyone in your household ever received mental health services?

Yes No

Are you currently working with an agency?

Yes No

Have you ever worked with a foster care agency in the past?

Yes No

ADOPTION/CFC INFORMATION

Where are you in this process?

First Steps Some Research Ready to Begin

I/we understand the process of adopting from foster care

Agree Disagree Moderately

I/we understand the home study process

Agree Disagree Moderately

I/we understand the needs of the children in care

Agree Disagree Moderately

I/we understand the typical age of children

Agree Disagree Moderately

I/we understand the concept of “legal risk” in adoption

Agree Disagree Moderately

Do you know others who have adopted or fostered?

Yes No

Do you know others who have adopted from foster care?

Yes No

Do you know others who have been adopted or fostered?

Yes No

Do you know the difference between CFC and DCF foster care?

Yes No

Which program are you interested in? (Select all that apply)

Adoption Comprehensive Foster Care

What are your reasons for pursuing adoption or foster care? Please describe

Best way to contact you (person, number, days and times?)

Or print and mail back this questionnaire to our Foster Care & Adoption Team

The Home for Little Wanderers
Attn: Center for Permanency
415 Neponset Street, 3rd Floor
Boston, MA 02122

THE HOME FOR LITTLE WANDERERS

Adoption & Comprehensive Foster Care MAPP Pre-Screening

Inquirer 1

Inquirer 2

Please answer the following questions. Your answers will be used to determine areas for further discussion

Additional Household Members

HOUSEHOLD INFORMATION

CHILD INTEREST CHARACTERISTICS

Personal Information (please respond for either inquirer as applicable)

ADOPTION/CFC INFORMATION

STAY HOPEFUL

GET TO KNOW THE HOME

GET INVOLVED

MAKE A DIFFERENCE

JOIN US