FAMILY PHOTO	FAMILY NAME AND COUNTY OF RESIDENCE

FAMILY COMPOSITION,

FIRST NAME, RELATIONSHIP IN FAMILY, AGE, AND RACE	TYPE OF CHILD DESIRED AGE RANGE, GENDER, RACE, AND # OF CHILDREN	LEGAL RISK

PLACEMENT	COMMENTS FAMILY STRENGTHS AND SPECIAL CHARACTERISTICS
Family Name

County of Residence	First Name

Relationship

Age / Race	Type of Child

Age Range

Gender

Race

# of Children	Legal Risk Placement	Comments etc.

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/

/

/

/

/

/

FAMILIES AT A GLANCE

(Month, Year)

Diakon / FDR – Waiting Families

Placement Benchmark – Benchmark Handbook – 11/02

FAMILY NAME, ADDRESS, PHONE

Childrens Services

2003-07-08

tmg

LHT