Disclosure of Family Violence

DISCLOSURE OF ANY FAMILY VIOLENCE CALLS TO A PROSPECTIVE FOSTER HOME APPLICANTS PLACE OF RESIDENCE

Texas Dept of Family and Protective Services
Form 2954
August 2007

“Texas law gives you the right to know what information is collected about you by means of a form you submit to a state government agency. You can receive and review this information, and request that incorrect information about you be corrected by contacting your licensing representative.”

Directions: To complete this form, the foster home applicant(s) must list each incident of law enforcement responding to a report of family violence at their place of residence in the 24 months preceding the application to become a foster home. Please include the location, the date, and a description of each incident. If law enforcement did not respond to any reports of family violence at the home, write NONE in the Description of Incident section. This form must be completed and reviewed during the home study process for each prospective foster home and filed in the foster home record.
List all incidents, locations, description, and dates of the family violence calls (if none, write NONE in the Description of the call).
Name of Child Placing Agency*
Date Received*
Month
Day
Year
Name of Home*
Date of the Family Violence Call*
Month
Day
Year
Current Home's Street Address*
Street Address Address Line 2 City State ZIP Code
Telephone No. (A/C)*
Street Address where the family violence call was made*
Street Address Address Line 2 City State ZIP Code
County*
Description of the call:*
Please give all of the details regarding the family violence call that was made to your place of residence, including why the call was made, who was involved, names and ages of foster children that were in the home at the time of the call and the names of anyone that was arrested.
Name of Child Placing Agency
Date Received
Month
Day
Year
Name of Home
Date of the Family Violence Call
Month
Day
Year
Current Home's Street Address
Street Address Address Line 2 City State ZIP Code
Telephone No. (A/C)
Street Address where the family violence call was made
Street Address Address Line 2 City State ZIP Code
County
Description of the call:
Please describe the family violence, including why a report to law enforcement was made, who was involved, names and ages of all children in the home at the time of the call, and the name of anyone who was arrested. Please attach a separate sheet of paper if more space is needed.
The information given is true and complete to the best of my knowledge. The failure or refusal of the applicant to sign or provide the required information constitutes good cause not to verify my home.
Signature of Prospective Foster Parent*

By entering your name, you are signing the above form and verifying that all information is correct.
Email*
Date*
Month
Day
Year
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