Madison County CASA
731-427-5554

Email:

Homestudy Assessment:

Volunteer Assigned:
Date of Home Study:

Home Evaluated:
How long at current address:
The information contained in this report has been gathered as ordered by the court.
It is designed for informational purposes only and is NOT intended to be used as the
sole basis for placement of the child(ren) in question.

CHILD(REN) TO BE PLACED

1. Name:DOB:
2. Name:DOB:
3. Name:DOB:
4. Name:DOB:
5. Name:DOB:

Special medical or emotional needs:

PROPOSED CARETAKERS

1. Full legal name:
Age: Relationship to children:
Any arrest record in any county/state?

If yes, please give dates, charges, and outcome:

Employer:
How long employed there?Employer Phone #:
Any history of mental illness requiring treatment by a mental health professional?:

If yes, gives dates, diagnosis, and treatment

Any history of drug/alcohol abuse?:
If yes, give dates, drug of choice, and treatment:


 

2. Full legal name:
Age: Relationship to children:
Any arrest record in any county/state?If yes, please give dates, charges, and outcome:

Employer:
How long employed there?Employer Phone #:
Any history of mental illness requiring treatment by a mental health professional?:

If yes, gives dates, diagnosis, and treatment

Any history of drug/alcohol abuse?:
If yes, give dates, drug of choice, and treatment:

WHO ELSE LIVES IN THE HOME?

1. Name:
Relationship to caretakers:
Age:Relationship to children:
Are they permanent residents: yes no 

If no, how long will he/she stay:
Does this person have a criminal record: yes no
If yes, give dates, charges, and outcome:

2. Name:
Relationship to caretakers:
Age:Relationship to children:
Are they permanent residents: yes no 

If no, how long will he/she stay:
Does this person have a criminal record: yes no
If yes, give dates, charges, and outcome:

INFORMATION ABOUT THE HOUSE

How many bedrooms are in the home?

Describe sleeping arrangements for the occupants of this home:

Is the house clean?
Is there an adequate amount of food in the house?
Was food stored or disposed of properly?
Does the child/children have adequate/appropriate clothing?
Do adults in the home have a room that allows for privacy? yes  no
Were alcohol, cleaning agents, guns, and other hazardous materials kept out of reach of children?
Describe child proofing measures that you have taken or will take if these children come to live with you :

Are there age appropriate toys?

FIRE SAFETY

Were working smoke detectors present in the home? Note how many and in which rooms:

Were any windows or doors painted or nailed shut or otherwise
obstructed in a manner that would prevent them from being used as emergency exits?


Additional notes/comments related to the home itself:

FINANCIAL POSITION OF CARETAKERS

Current monthly household income by source:
Current monthly household expenses:
Caretaker’s estimate of additional expenses that will be incurred if the child(ren) are placed in this home:
Plan to cover these additional expenses:

DISCIPLINE PRACTICES

Preferred method of discipline:

What types of behavior would children this age do to require disciplinary action?

Additional notes/comments relating to child discipline practices:
SUPPORT SYSTEMS

Who do you consider to be part of your support system? Examples might be church, friends, counselors, extended family members, etc.

What child-care plans have you made for these children
(school, daycare, sitters, etc.)?

Any other comments or concerns the court should be aware of?