Cy 131 Form PDF Details

Embarking on the journey to become a resource family entails various steps, one of which includes completing the Resource Family Applicant Registration / Update Form, known as the CY 131 form. This document serves as a crucial tool in Pennsylvania's effort to streamline the process for families aspiring to adopt or foster, ensuring that all necessary personal and household information is meticulously collected and updated. The form, which must be mailed to the Pennsylvania Adoption Exchange in Harrisburg, PA, is comprehensive, covering a wide range of topics from basic family demographics to more detailed inquiries about the family's background, home environment, and preferences regarding the children they wish to foster or adopt. Applicants are required to provide information including names, social security numbers (which are requested but not mandatory), contact information, marital status, and a detailed history of previous addresses. Additionally, the form delves into the family's composition, asking for specifics about other household members and any changes therein. Prospective resource families must also disclose their disposition towards various types of foster care or adoption scenarios, detail any agency affiliations, and articulate their preferences concerning the characteristics of children they feel equipped to support. By encompassing everything from racial and ethnic considerations to the special needs and behavioral characteristics that families are willing to accommodate, the CY 131 form plays an integral part in facilitating successful placements that benefit both the children in need and the families eager to welcome them.

QuestionAnswer
Form NameCy 131 Form
Form Length5 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 15 sec
Other namescy131update, PENNSYLVANIA, CW, Islander

Form Preview Example

RESOURCE FAMILY APPLICANT REGISTRATION / UPDATE FORM (CY 131)

Mail to:

PENNSYLVANIA ADOPTION EXCHANGE

P.O. Box 4469

Harrisburg, PA 17111-0469

800-227-0225

SWAN ID #

PAE ID #

For updates: Complete Agency Information

section, shaded entry blocks and all information that has changed.

FAMILY DEMOGRAPHICS

All fields must be filled out unless noted

PARTNER #1

LAST NAME

DATE OF BIRTH

FIRST NAME

SOCIAL SECURITY # (Requested)

MI

GENDER

MALE FEMALE

TELEPHONE (Daylight)

( )

RACE AND ETHNICITY - Check all that apply

RACE: American Indian / Alaskan Native

Asian

Black / African American

Native Hawaiian / Other Pacific Islander

White

ETHNICITY HISPANIC: YES NO

 

 

 

 

 

 

 

 

 

PARTNER #2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LAST NAME

 

 

 

FIRST NAME

 

MI

 

GENDER

 

 

 

 

 

 

 

 

 

MALE FEMALE

DATE OF BIRTH

 

SOCIAL SECURITY # (Requested)

 

TELEPHONE (Daylight)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

RACE AND ETHNICITY - Check all that apply

 

 

 

 

 

 

 

RACE: American Indian / Alaskan Native

Asian

Black / African American

Native Hawaiian / Other Pacific Islander

White

ETHNICITY HISPANIC: YES NO

 

 

 

 

 

 

 

 

 

STREET ADDRESS

 

 

 

 

 

 

E-MAIL

 

 

 

 

 

 

 

 

 

 

 

CITY

STATE

ZIP

COUNTY

APPLICANT(S) MARITAL STATUS

Married Single Alternative Lifestyle Other __________________

PREVIOUS FAMILY ADDRESSES

List all home addresses for the previous 10 years (attach additional page, if needed) OR Not Applicable

STREET

CITY

STATE

ZIP

COUNTY

STREET

CITY

STATE

ZIP

COUNTY

STREET

CITY

STATE

ZIP

COUNTY

STREET

CITY

STATE

ZIP

COUNTY

STREET

CITY

STATE

ZIP

COUNTY

ALL OTHER MEMBERS OF HOUSEHOLD

Attach additional page, if necessary, OR Not Applicable

For families already registered ONLY: If adding or removing a member of the household, check New or Delete as appropriate

NAME

DATE OF BIRTH

GENDER

RELATIONSHIP

SOCIAL SECURITY

New

TO APPLICANTS

# (Requested)

 

 

 

 

 

 

 

 

 

 

Delete

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Rev. 05-10

FAMILY INFORMATION

Please answer the following questions.

1.List the occupations of the applicants, including a stay-at-home parent.

Partner 1 __________________________________

Partner 2 __________________________________

2.List any special needs training applicants have.

3. Select the type of neighborhood where applicants live.

Rural

FAMILY DISPOSITION

 

 

 

Disposition:

APPROVED

DISAPPROVED

CLOSED

For type of care:

ADOPTIVE

FOSTER CARE

KINSHIP

Urban Suburban

DATE of DISPOSITION

Please choose type of foster care approval or reason for any disapproval or closure below.

APPROVED - For foster care, choose type of approval

FULL

REGULATION WAIVER GRANTED

DISAPPROVED - Choose reason

CHILD ABUSE HISTORY

CRIMINAL HISTORY

FAILURE TO COMPLETE TRAINING

FAILURE TO FOLLOW AGENCY POLICY

FALSIFICATION / MISREPRESENTATION OF INFORMATION

UNFAVORABLE FAMILY PROFILE

OTHER Explain:

________________________

CLOSED - Choose reason

Adopted child from PA child welfare system

Adopted child from another state (CW)

Adopted privately / domestically

Adopted internationally

Kinship adoption

Kinship care – not adoption

Kinship home-child no longer in home

Permanent Legal Custodian

Family unresponsive

Moved to other agency

Moved away

No longer interested / personal reasons

Other reason: __________________

If closing a previously registered, approved family, complete all shaded areas of the form and the Agency Information section. Sign and date below. I certify that the information provided is accurate and complete.

Signature______________________________________ Date _________________________

FOSTER FAMILY APPEAL ACTIVITY

FAMILY FILED APPEAL

LIST ANY RESTRICTIONS TO APPROVAL

BASIS FOR APPEAL

REGISTERING AGENCY

APPEAL UPHELD

DATE

APPEAL DENIED

 

AGENCY INFORMATION

REGISTERING AGENCY

 

 

 

 

CASEWORKER (Full name)

 

 

 

 

 

 

MAILING ADDRESS

 

 

 

 

E-MAIL

 

 

 

 

 

 

CITY

 

STATE

ZIP

 

COUNTY

 

 

 

 

 

 

TELEPHONE #

 

 

 

FAX #

(

)

 

 

 

 

ALL PREVIOUS FOSTER CARE / ADOPTION AGENCY AFFILIATIONS or Not Applicable Attach additional page, if needed

PREVIOUS AGENCY

 

 

 

 

CASEWORKER (Full name)

 

 

 

 

 

 

MAILING ADDRESS

 

 

 

 

E-MAIL

 

 

 

 

 

 

CITY

 

STATE

ZIP

 

COUNTY

 

 

 

 

 

 

TELEPHONE #

 

 

 

FAX #

(

)

 

 

 

 

Page 2 of 5

Rev. 05-10

ALL PREVIOUS FOSTER CARE / ADOPTION AGENCY AFFILIATIONS (continued)

PREVIOUS AGENCY

MAILING ADDRESS

CITY

TELEPHONE #

( )

STATE

ZIP

FAX #

CASEWORKER (Full name)

E-MAIL

COUNTY

TYPE OF CHILD APPROVED FOR FAMILY

WHAT IS THE MAXIMUM NUMBER OF CHILDREN APPROVED FOR THIS FAMILY’S HOME? ___________

SPECIAL NEEDS

CHECK ALL SPECIAL NEEDS FAMILY IS APPROVED TO PROVIDE.

NOT APPLICABLE

ABUSE HISTORY

NEGLECT HISTORY

 

ALCOHOL EXPOSED

PHYSICAL DISABILITY

 

DRUG EXPOSED INFANT

RUNAWAY HISTORY

 

EMOTIONAL DISABILITY

SEXUAL ABUSE HISTORY

 

HIV

SIBLINGS: # _____________

 

MH DIAGNOSIS

SPECIAL EDUCATION STUDENT

 

MR DIAGNOSIS

SPECIAL MEDICAL CARE

 

MULTIPLE PLACEMENT HISTORY

OTHER: __________________________________________________

TYPE OF CHILD FAMILY PREFERS - If family is disapproved, check Not Applicable

RACE / ETHNICITY - Check all family will accept

RACE:

AMERICAN INDIAN / ALASKAN NATIVE

ASIAN

BLACK / AFRICAN AMERICAN

NATIVE HAWAIIAN / OTHER PACIFIC ISLANDER

WHITE

ETHNICITY HISPANIC: YES NO

GENDER

MALE

FEMALE

EITHER

NUMBER OF CHILDREN & AGE RANGE

AGE RANGE:

BETWEEN ______ and _____ YEARS

NUMBER OF CHILDREN:

SINGLE CHILD

SIBLINGS

MAXIMUM NUMBER _________

STOP HERE if match suggestions are not needed

CHARACTERISTICS OF CHILD

For adoptive families only: Please choose from the characteristics listed to tell us the type of child the family wants to adopt. Place an X in the most appropriate box for each characteristic.

HEALTH

Characteristic

1.No significant health problems

2.Allergies or asthma (may require treatment)

3.Hyperactivity (may require treatment)

4.Speech problems (may require treatment)

5.Hearing problems (may require treatment)

6.Legally deaf

7.Vision problems (may require treatment)

8.Legally blind

9.Dental problems (may require treatment)

10.Orthopedic problems (special shoes, brace, etc.)

11.Seizure disorder

Acceptable

Will

Consider

Unacceptable

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Rev. 05-10

 

EDUCATION

 

Characteristic

Acceptable

Will

Consider

 

 

12.High achiever

13.Achieves on grade level in regular classes

14.Achieves below grade level in regular classes

15.Needs special education classes

16.Needs learning disability classes (LD)

17.Needs classes for the emotionally or behaviorally handicapped

18.Needs tutoring in one or more subjects

19.Has serious behavior problems at school

Unacceptable

CHARACTERISTICS AND BEHAVIORS

Characteristic

Acceptable

Will

Unacceptable

Consider

 

 

 

20.Generally quiet and shy

21.Generally outgoing and noisy

22.Emotional issues require ongoing therapy

23.Tends to reject father figures

24.Tends to reject mother figures

25.Difficulty making friends and relating to other children.

26.Frequently wets the bed.

27.Frequently wets during the day

28.Frequently soils him/herself

29.Masturbates frequently or openly

30.Poor social skills

31.Problem with lying

32.Problem with stealing

33.Frequently starts physical fights with other children

34.Tends to abuse animals

35.Tends to be destructive of clothing, toys. etc.

36.Frequently uses foul or bad language

37.Frequent temper tantrums

38.Difficulty accepting and obeying rules

39.History of inappropriate sexual behavior

40.History of running away

41.History of playing with matches, setting fires

FAMILY CONNECTEDNESS & HISTORY

Characteristic

Acceptable

42.Strong ties to birth family

43.Strong ties to foster family

44.Needs continued contact with siblings

45.Previous adoptive disruption

46.Sexually abused

47.Exposed to promiscuous sexual behavior

48.Conceived by rape

49.Conceived as a result of prostitution

Will

Consider

Unacceptable

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Rev. 05-10

50. One or both parents addicted to alcohol

FAMILY CONNECTEDNESS & HISTORY

Characteristic

51.One or both parents chemically dependent, other than alcohol

52.One or both parents has criminal record

53.One or both parents mentally retarded

54.One or both parents has mental illness

55.No information available about one or more parent

Acceptable

Will

Consider

Unacceptable

RESOURCE FAMILY’S FEELINGS ABOUT OPENNESS WITH BIRTH FAMILY

Characteristic

56.Meet with birth parents

57.Contact with birth parents through agency or intermediary

58.Send letters to birth parents

59.Receive letters from birth parents

60.Send videos to birth parents

61.Receive videos from birth parents

62.Have phone contact between adults

63.Child continues visits with siblings

64.Child continues visits with extended relatives in birth family

65.Child continues visits with birth parents

66.Receive birth parents’ name, address, phone number, etc.

67.Adoptive parents willing to give first name to birth parents

68.Adoptive parents willing to give identifying information to birth parents

Acceptable

Will

Consider

Unacceptable

SIGNATURE OF AGENCY WORKER REQUIRED

I verify that this information is accurate and complete to the best of my knowledge or information and belief. The information is submitted as true and correct under penalty of law (Section 4904 of the Pennsylvania Crimes Code).

_______________________________________

________________

AGENCY WORKER

DATE

 

 

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Rev. 05-10