Children’s Bio Card Questionaire - Heart Gallery of America



2008 Children’s Bio Card Questionnaire

FOR 5 YEAR OLDS & UNDER

PART A :

Child’s Complete Name _______________________________________ Child’s Age ____________

(Please take a moment to double check the spelling, will be printed as written on image.)

Child’s Birthday (dd/mm/yy) _________________ Current Grade Level _________

(Complete Birthday is required, please double check for accuracy.)

Location of current home (ex: Plant City, South Tampa, etc.) __________________________________________________

(Please be as specific as possible.)

Currently at a Group Home? Y or N If yes, Name of Group Home ________________________________________

Child’s School _______________________________________________

Is this child part of a sibling group? Y or N

Please list the names and ages of the siblings: __________________________________________________________

________________________________________________________________________________________________________

This child WOULD _____ or WOULD NOT _____ adopt separately from his/her siblings.

Does this child have special needs? Y or N If yes, please explain: ___________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

PART A : Continued

2008 Children’s Bio Card Questionnaire

FOR 5 YEAR OLDS & UNDER

Please answer the following questions as fully as possible. Focusing on the positive aspects of the child and identifying qualities that make him/her a unique individual will be a wonderful help in creating a dynamic and engaging biography.

1.) What are five of this child’s best characteristics?

_________________________________ _________________________________ _________________________________

__________________________________ __________________________________

2.) What does this child excel at above all else? Please cite academic and social examples. (Example: math and reading; telling the truth, helping others, etc.)

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

3.) In social situations, how does this child behave? (example: he/she is outgoing and friendly; shy and withdrawn; the entertainer and prankster, loving, etc.)

_________________________________________________________________________________________________________

4.) What makes this child unique?

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

5.) This child is loved by others because ______________________________________________________________________

_________________________________________________________________________________________________________

6.) She/he should be proud of her/himself, because ____________________________________________________________

_________________________________________________________________________________________________________

7.) This child would make an excellent daughter/son because ____________________________________________________

_________________________________________________________________________________________________________

Continue to next page…

2008 Children’s Bio Card Questionnaire

FOR 5 YEAR OLDS & UNDER

PART B: Please fill out with child, by asking the questions and transcribing.

1. What is your favorite animal and why? _____________________________________________________________________

2. What is your favorite game? ______________________________________________________________________________

3. What is your favorite place? ______________________________________________________________________________

4. List three things you love about yourself. (Example: funny, athletic, smart, etc.)

_________________________________________________________________________________________________________

5. What would you like to be when you grow up? _______________________________________________________________

_________________________________________________________________________________________________________

6. What kind of music do you like? ___________________________________________________________________________

7. What are your three favorite things to do? (Example: play outside, draw, play an instrument, etc.)

_________________________________________________________________________________________________________

8. Do you like to play sports? If so, which ones? ________________________________________________________________

9. What three things make you most happy? __________________________________________________________________

Fill in the blank:

On a rainy day, I like to ___________________________________________________________________________________.

On a sunny day, I like to ___________________________________________________________________________________.

I’m very special and unique because _________________________________________________________________________.

The one thing I would like people to know about me is _________________________________________________________.

One of the most important things to me is ____________________________________________________________________.

Thanks for your time! Love, the Heart Gallery Tampa Bay

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Please submit to Jesse Miller by Thurs. Sept. 20th by faxing to 813.228.8122

(fax cover sheet enclosed in CM packet)

Please type or write in legible print and be as thorough and positive as possible.

Part A – To be filled out by care manager

Part B – To be asked to the child and transcribed by the care manager

Care Manager Name ________________________________ Cell Number ______________________

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