MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION FAMILY RESPONSE FORM
Name of Family Completing this Response	Resource Development Worker
Name of Child(ren) to be placed	Child’s Case Manager
The Family Response Form (CD-192) is developed in tandem with the Child’s Adoption Summary. It should be completed by the prospective adoptive family, and not by an agency worker on behalf of the family. The purpose of this form is to gather pertinent family information, and to provide the family an opportunity to describe how they can meet the individualized needs of the child or sibling group. The Child’s Adoption Summary and Family Response Form (CD-192) are used together during the Adoption Staffing Process.
General Information
1. Describe the current members of your household.
2. Describe the changes in your family, including the addition of foster children, since your last adoptive home assessment.
3. Describe how you learned about the child(ren), and why you are interested in the child(ren).
Legal Status and Permanency Plan
4. What is your understanding of the child’s current legal status/permanency plan?
5. What is your opinion of the child’s current understanding of adoption?
Sibling Relationships
6. Is the child you are being considered for a member of a sibling group? Yes No
7. Are the siblings being placed together? Yes No
8. For children being placed separate from their siblings – answer the following question: If this child is placed with you, how will you help the child continue relationships with siblings?
Child Connections and Relationships
9. If this child is placed with you, how will you help the child continue relationships with individuals and groups that are important to him/her?
Placement History
10. What is your understanding of the reasons the child was placed in CD custody?
11. If this child is placed with you, how will the child’s past placements (including previous adoption disruptions) impact you?
Medical/Dental, Developmental/Emotional and Educational Needs
12. Describe what you think will be the challenges of parenting a child with the specific needs of this child, as related to:
Medical/Dental
Developmental
Behavioral and Emotional
Educational
Other specific need
13. Describe specific training, experience, knowledge or strengths you have that will help you meet the specific needs of this child as related to:
Medical/Dental
Developmental
Behavioral and Emotional
Educational
Other specific need
14. Based on the child’s needs, describe ways your family will accommodate the additional appointments and services the child may need.
Personality, Values and Traditions
15. Based on what you have learned about this child’s personality, values and traditions, describe how he/she will fit into your family.
16. If this child is placed with you, describe how you will help the child maintain his/her identity and continue to develop traditions, values and beliefs that are important to him/her.
Daily Routine
17. Based on what you have learned about the child’s daily routine; describe how he/she will fit into your family.
18. Describe how your family can meet this child’s need for structure and/or flexibility.
Other Significant Information
19. Identify the supports that are available within your family and your community to meet the specific needs of the child.
20. What changes do you anticipate in your family if this child is placed with you?
21. Have any children disrupted from your home? Yes No
22. If so, what were the circumstances?
23. What did you learn from that experience?
24. What else would you like to tell us?
Name of Person Completing Form	Date Form Completed