Screener Detail

My Age *

How many people live in your home? *

My monthly household income is:

$

Do you have children or are you pregnant?

Yes

No

Do you share custody of your child(ren)?

Yes

No

Do you need financial support to raise your child(ren)?

Yes

No

Are you on a Dependency & Neglect Case?

Yes

No

I'm Interested in Foster Care and/or Adoption

I’m interested in becoming a caregiver for an at risk elderly or disabled adult

I know someone who Needs Help

Is this individual a child/youth ?

Yes

No

Is this individual an at-risk adult?

Yes

No

There was a recent Death in my Family