MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION PERSONAL REFERENCE QUESTIONNAIRE
FROM:	Resource Licensing Worker	Telephone Number	Date
Agency and Address
City	State	Zip Code
Agency Contact	Office Hours
TO:	Reference Name	Telephone Number
Address (Street)
City	State	Zip Code
RE:	Applicant(s)
The above named applicant(s) has applied to the Missouri Children’s Division to serve as foster/relative/adoptive parents. In order to complete our assessment of their application, it is necessary that we obtain information about the family. Please complete the information below in as much detail as possible and attach a separate sheet if necessary. If you have questions or need assistance in completing this form, please call the Resource Licensing Worker listed above.
1. How long have you known this couple/person?	2. In what way have you known them? (Socially, neighbor, business, etc.)
3. Their reputation in their community is:	Superior Above Average Average Below Average Poor
(Please explain any negative answer)
4. What past experience have they had with children? (Their own or others)
5. What type of care are they giving children now in their home?
6. Are you familiar with their method of discipline? Yes No Can you describe their methods?
7. Please describe their marital relationship.	Above Average Average Below Average Poor
(Please explain)
8. Do you know of any physical, psychological, or behavioral problems which might interfere with their being successful foster/relative/adoptive parents? (Please include comments about their use of alcohol, drugs, time, money, extreme nervousness, temper, or other things you think are important.)
Do you feel that they would be able to:
1.	Protect and nurture children in their home?	Yes No
2.	Meet children's developmental needs and address developmental delays?	Yes No
3.	Support relations between children and their families?	Yes No
4.	Connect children to safe, nurturing relationships intended to last a lifetime?	Yes No
5.	Work as a member of a professional team?	Yes No
1. Reference's Signature	Date	Occupation
Print/Type Reference’s Name:
2. Reference's Signature	Date	Occupation
Print/Type Reference’s Name: