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2. Greene County Family and Children First

   Disclaimer: Information submitted on this on-line form will be sent via email. If you would prefer to provide information in another form, please find on our website the PDF format of this Questionnaire.   You will need to print this Home Study Questionnaire out, fill it out completely and mail it to:   Greene County Family and Children First, Attention: Family Relations, 158 East Main Street, Xenia, Ohio 45385

   
   

4. HOMESTUDY QUESTIONNAIRE

   Please complete this form in it's entirety and attach any supplemental documents before submitting. For questions, please contact Leslie Grayson or Rose Hoersting at: leslie.grayson@greenecountyohio.gov ;  rose.hoersting@greenecountyohio.gov ;  OR  (937) 562-5600.

6. Full Name: (First, Middle, Last)*
7. Maiden Name
9. Street Address (Include Apartment. Number.):*
11. City:*
12. State:*
13. Zip Code:*
15. Date of Birth (month/day/year):*
16. Social Security # ( ex. 222-22-2222):*
18. Email Address:*
20. Driver License #:
21. Do you have a Current Valid Driver's License?

    1. YES
    2. No
23. Phone Number: Home (*with area code)
24. Phone Number: Cell (*with area code)
28. Addresses in the last five (5) years -- (Include shelter residences):
30. 1) Street Address, City, State and Zip Code:
32. 2) Street Address, City, State and Zip Code:
34. 3) Street Address, City, State and Zip Code:
36. 4) Street Address, City, State and Zip Code:
38. 5) Street Address, City, State and Zip Code:
40. Other Counties / States where you have resided in:
44. Please list the following regarding all other adults who reside with you:
46. Name:
47. Date of Birth (mo./day/year):
48. Social Security # :
50. Name:
51. Date of Birth (mo./day/year):
52. Social Security #:
54. Name:
55. Date of Birth (mo./day/year):
56. Social Security #:
58. Name:
59. Date of Birth (mo./day/year):
60. Social Security #:
62. Do you currently have a companion living with you?

    1. YES
    2. NO
63. Name of companion:
64. Companion's Social Security #:
68. PERSONAL INFORMATION:
70. Are you presently married?

    1. YES
    2. NO
71. Date of marriage (month/day/year):
72. Place of marriage:
74. Name of spouse:
76. Spouse's Birth Date (month/day/year):
77. Spouse's Social Security # (ex.222-22-2222):
79. Name of your former spouse:
80. Date of Marriage / Date of Divorce:
81. Location of Divorce:
83. Name of your former spouse:
84. Date of Marriage / Date of Divorce:
85. Location of Divorce:
87. Does your present spouse or companion have children from a former marriage or relationship?

    1. YES
    2. NO
89. 1) Name:
90. Age:
91. Custodian:
93. 2) Name:
94. Age:
95. Custodian:
97. 3) Name:
98. Age:
99. Custodian:
101. Do you have children who are NOT at issue in this case OR who reside with others? If so, please list:
103. 1) Name:
104. Birthdate (mo./day/year):
105. Age:
107. School:
108. School Hours:
110. Name of the custodian of this child:
112. 2) Name:
113. Birthdate (mo./day/year):
114. Age:
116. School:
117. School Hours:
119. Name of the custodian of this child:
123. EMPLOYMENT STATUS
125. EMPLOYER:
126. JOB TITLE:
128. WORK HOURS:
129. PHONE NUMBER (*with area code):
131. CAN YOU BE CONTACTED AT WORK?
132. DATE OF HIRE (month/day/year):
134. HAVE YOU EVER BEEN FIRED?

     1. YES
     2. NO
135. If YES, please explain:
137. ANY PLANS TO RELOCATE?
139. SPOUSE / COMPANION EMPLOYER:
140. WORK HOURS:
144. INCOME:
146. YOUR GROSS MONTHLY INCOME:
147. SPOUSE / COMPANION GROSS MONTHLY INCOME:
149. YOUR ADC OR FOOD STAMPS:
150. SPOUSE/COMPANION ADC OR FOOD STAMPS:
152. YOUR CHILD / SPOUSAL SUPPORT REC'D:
153. SPOUSE/COMPANION CHILD/SPOUSAL SUPPORT REC'D:
155. YOUR OTHER INCOME:
156. SPOUSE/COMPANION OTHER INCOME:
158. YOUR TOTAL MONTHLY EXPENSES (Include rent, utilities, debts, etc.):
159. SPOUSE/COMPANION TOTAL MONTHLY EXPENSES (Include rent, utilities, debts, etc.):
161. DO YOU PAY CHILD SUPPORT?

     1. YES
     2. NO
162. ARE YOU CURRENT?

     1. YES
     2. NO
164. AMOUNT:
165. IF NOT CURRENT, PLEASE EXPLAIN:
169. EDUCATION:
171. ARE YOU A HIGH SCHOOL GRADUATE?

     1. YES
     2. NO
172. GED

     1. YES
     2. NO
173. IN SCHOOL NOW?

     1. YES
     2. NO
175. LAST GRADE COMPLETED:
176. COLLEGE / MAJOR:
180. HEALTH & WELLNESS:
182. Do you or your spouse/companion have any chronic illness or disabilities?
184. Have you, your spouse or companion, been hospitalized in the last five years? If yes, please indicate who / where / when:
186. Do you, or your spouse/companion, drink alcoholic beverages?

     1. YES
     2. NO
187. If yes, explain the frequency:
189. Please describe any past or present illegal drug use for you, your spouse and/or companion:
191. Name of CURRENT Mental Health Physician/Counselor(s):
192. Phone Number (*with area code):
194. Street Address, City, State and Zip Code
196. Name of CURRENT Medication Management Physician(s):
197. Phone Number (*with area code):
199. Street Address, City, State and Zip Code
203. HAVE YOU PARTICIPATED IN COUNSELING FOR ANY OF THE FOLLOWING?
205. SUBSTANCE ABUSE

     1. YES
     2. NO
206. ANGER MANAGEMENT

     1. YES
     2. NO
207. MENTAL HEALTH

     1. YES
     2. NO
208. PARENTING

     1. YES
     2. NO
210. If YES, please list NAME OF SERVICE PROVIDER(s), DATE OF SERVICE(s), and PHONE NUMBER(s) *with area code.
212. Do you, your spouse/companion have any past or present mental health diagnosis that requires treatment and/or medication? If YES, please explain:
216. CRIMINAL HISTORY AND/OR SUPPORTIVE SERVICES HISTORY:
218. ARE YOU CURRENTLY LISTED IN A CPO/TPO?

     1. YES
     2. NO
219. HAVE YOU BEEN CONVICTED OF A CHILD-RELATED CRIME?

     1. YES
     2. NO
220. HAVE YOU BEEN CONVICTED OF A CRIME RELATED TO DOMESTIC VIOLENCE?

     1. YES
     2. NO
221. HAVE THE POLICE BEEN CALLED TO YOUR HOME FOR DOMESTIC PROBLEMS?

     1. YES
     2. NO
223. HAVE YOU OR YOUR CHILDREN BEEN INVOLVED WITH CHILDREN SERVICES?

     1. YES
     2. NO
224. If YES, please state DATE(s) (month/day/year) and LOCATION:
226. YOUR ARREST HISTORY. (Please include the DATE (month/day/year), PLACE, and DISPOSITION):
228. YOUR CURRENT SPOUSE OR COMPANION'S ARREST HISTORY. (Please include DOMESTIC VIOLENCE and CHILD RELATED CRIME(S), as well as the DATE (month/day/year), PLACE and DISPOSITION):
230. ARE YOU CURRENTLY ON PROBATION?

     1. YES
     2. NO
231. NAME, LOCATION, TELEPHONE NUMBER (*with area code) OF PROBATION OFFICER:
233. PLEASE LIST ANY KNOWN HISTORY OF POLICE, DOMESTIC, OR CHILD-SERVICES INVOLVEMENT REGARDING THE OTHER PARTY (PARENT) IN THIS CASE (parenting issues are addressed later in the questionnaire):
237. CHILDREN AT ISSUE:
239. 1) NAME:
240. DATE OF BIRTH (mo./day/year):
241. AGE:
243. SCHOOL:
244. SCHOOL HOURS:
246. NAME OF CUSTODIAN OF THIS CHILD:
248. 2) NAME:
249. DATE OF BIRTH (mo./day/year):
250. AGE:
252. SCHOOL:
253. SCHOOL HOURS:
255. NAME OF CUSTODIAN OF THIS CHILD:
257. 3) NAME:
258. DATE OF BIRTH (mo./day/year):
259. AGE:
261. SCHOOL:
262. SCHOOL HOURS:
264. NAME OF CUSTODIAN FOR THIS CHILD:
266. 4) NAME:
267. DATE OF BIRTH (mo./day/year):
268. AGE:
270. SCHOOL:
271. SCHOOL HOURS:
273. NAME OF CUSTODIAN FOR THIS CHILD:
275. CURRENT PARENTING TIME SCHEDULE:
277. DESCRIBE YOUR CHILD/CHILDREN'S PERFORMANCE IN SCHOOL:
279. DOES YOUR CHILD/CHILDREN DISPLAY ANY EMOTIONAL OR BEHAVIORAL PROBLEMS AT HOME OR IN SCHOOL?
281. LIST THE CHILD/CHILDREN'S ACTIVITIES:
283. NAME OF BABYSITTER OR DAYCARE:
284. PHONE NUMBER (*with area code):
286. BABYSITTER OR DAYCARE'S ADDRESS: (Street Address, Apartment Nr, City, State and Zip Code)
288. NAME OF CHILD/CHILDREN'S PHYSICIAN:
289. PHONE NUMBER (*with area code):
291. STATE ANY HEALTH ISSUES CHILD/CHILDREN HAVE:
293. NAME OF CHILD/CHILDREN'S COUNSELOR/PSYCOLOGIST:
294. PHONE NUMBER (*with area code):
296. COUNSELOR/PSYCOLOGIST'S ADDRESS: (Street Address, City, State and Zip Code)
298. COUNSELING SCHEDULE:
300. REASON FOR COUNSELING:
302. IS YOUR CHILD AND/OR CHILDREN PRESECRIBED ANY MEDICATIONS? If YES, please list and explain:
304. EXPLAIN ANY CONCERNS YOU HAVE REGARDING YOUR CHILDREN'S CARE WHILE WITH THE OTHER PARENT/GUARDIAN:
Leave This Blank:


306. 1. Receive an email copy of this form.
307. Email address

     This field is not part of the form submission.

308. Submit

* indicates a required field