<p> Foster Home Needs Assessment (By County)</p><p>County: Supervisor: Date Completed: </p><p>Instructions: To complete the following grid, enter the total number of homes in the left column and then select the check box under each category heading that applies to the number you entered. The example listed in the grid below represents what you would enter if you needed:</p><p>Example: 4 homes that would accept black children of any gender, who are between the ages 12 to 15, who may be part of a sibling group of any number, who may have behavioral problems. 1 home that would accept a male child with no siblings of any race, any age who had sexually acted out. s s s r r m a d a s l s s i e e e e t l y g s h s y s y c n s s u b a n s e c l i e e n o i s e / l d l o m 5 1 i t d i O e t a i r r s n</p><p> b e l m e 1 w e r i r g m i l + – a b e</p><p>D s e P g e 3 5 2 4 6 o</p><p>S s r s r e e a a o b b</p><p>7 – d d l c e g e r n n r e f f f f f</p><p>0 i f r u i e n e d e e H a D o f n r c H l a t t</p><p> n l a</p><p>T I g e k o o F o o o r 6 n</p><p> o i a t s l y h n s e</p><p> t</p><p> o l s e e a c f a t i</p><p> l y t a e i c t a i</p><p> f a A n u i a r P e r y</p><p> p p p p p b f i h c o e 5 y a o l A h a n i D p c p t /</p><p> m e b</p><p> l l g e D</p><p> y r c u u u u u y n 1 r s l a R O s u e e l</p><p>M a y + M b n o A i B e O o o o o o W n l e y m</p><p> e i V l a n l o p r r r r r c a – 6 F I o x p i A g r n p v H b m c e A a g e s a n i r 1 t e s</p><p>G G G G G d H N o a 2 u g c A e u G l s o e m n y r e i S h 1 n a n o x y e t u e n e P m n a e v h M o y N t N A e M B E e S n P s m e b D A E T u S 4                                     1              S                       E  I S M B P E L E R G I C G A R E N I E G A N G A N E C D L C E E G Y R R N O E H U E O P D M S S E S</p><p>If you have any foster home needs that cannot be identified in the grid above, please describe the number and type of homes needs in narrative form below. Please be specific.</p><p>PRINTING INSTRUCTIONS: Left click “File”, then “Print”, then the down arrow by the words “No Scaling” (lower right corner of print window), then left click “Letter”, lastly left click “OK”.</p><p>CFS-445 (01/2005)</p>