Medical Letter for foster/adopt parents to complete.

1. MEDICAL LETTER
Date:
POTENTIAL FOSTER PARENT NAME:
POTENTIAL FOSTER PARENT NAME:
The above referenced individuals meet the following criteria:
1. is considered free of communicable disease;
2. has no known physical or mental condition which would be hazardous to, or impact negatively a foster or adoptive
child;
3. is considered able to accept responsibility for a foster or adoptive child without risking his or her own health;
4. is physically and mentally capable to be verified as a foster or adoptive parent; and
5. You have performed a urine drug screen and the results are as follows or attached to this letter.
Physician Name:
Physician Address:
Telephone #:
THE CLIENT DATE
THE CLIENT DATE
Latest Revision 06/01/09 Page 1 of 1 file: CPA Policies/Forms/Parent Files/Medical Letter