Health checklist

Thank you for your commitment to becoming a foster carer with Brophy Family and Youth Services. As part of your assessment, we ask you to complete this health checklist so we can better understand your health and wellbeing, and that of your household. This helps us ensure a safe, stable, and suitable environment for a child or young person in care. All information you provide is handled confidentially and in accordance with our Privacy and Confidentiality Policies. Please note: each applicant must complete a separate health checklist. If there are two applicants in your household, please ensure both individuals submit their own form.

Applicant details

Full legal name

Date of birth

Email address

Physical health

Do you have any illness or physical conditions?

Yes

Mental health

Have you had any psychological or mental health condition(s)?

Yes

Medical specialists

Have you seen any medical specialist in the past three years?

Yes

Medication

Do you use prescription medication?

Yes

Smoking

Do you smoke?

Yes

Alcohol

Do you drink alcohol?

Yes

Non-prescription and illicit drug use

Do you or other household members use non-prescription drugs, including illicit drugs?

Yes

Household members' health

Do any of your children or other household members have significant medical or other conditions (e.g. chronic illness, mental health conditions, disabilities)?

Yes

Acknowledgement

Full legal name

Signature