Application to become a therapuetic foster parent
Life Opportunities, Inc Life Opportunities providing families and children behavioral and emotional therapeutic services and foster home support.
120 S Main St Red Springs NC 28377
910-843-1105
Life Opportunities, Inc
LOTHS logo 2

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Application for Therapuetic Foster Parents

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Do you own a car?
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Last Grade Completed:
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Marital Status
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Do you own a car?
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Last Grade Completed:
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Marital Status
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Type of Home:
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Source of Water Supply
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Others In Household:

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Sex
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Sex
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Sex
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Please Identify others in household who have special physical and/or educational needs:
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Children out of the home:

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Sex
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Do you have relatives within 25 mile radius:
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How did you hear about the LOTHS's Therapeutic Home Program?
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Have you applied to be an adoptive or Therapeutic Parent before?
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If YES
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Children Preferred:

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Would you be a Therapeutic Parent to a child with special emotinal needs?
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Have you ever been charged or convicted of an offense against the law, other than a minor traffic violation?

Wife
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Husband:
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Have you ever been investigated for child abuse or neglect?

Wife
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Husband:
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If YES, was it substantiated?
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Please list 3 references each.

(References connot be related to you. At least one reference must be from a current or previous supervisor. Please include apartment numbers, lot numbers and zip codes.)

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Financial Statement

This financial statement is requested to verify that you have a sufficient income to meet your family's needs without income you would receive for providing therapeutic care.

Are you or a member of your family active or retired military?
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Monthly Income:

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Monthy Expenses

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By clicking agree, I certify (to the best of my knowledge)the information provided in this application is true and accurate.

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Life Opportunties Therapeutic Home Services

LOTHS Fayetteville Office
806 Stamper Rd – Suite 202
Fayetteville, NC 28303

1 (910) 764-0255
info@LOTHS.org
LOTHS Red Springs Office
120 S Main St.
Red Springs, NC 28377

(phone) 1 (910) 843-1105
(fax) 1 (910) 843-1295
LOTHS Rockingham Office
912 E. Broad
Rockingham, NC 28345

(phone) 1 (910) 817-7978
(fax) 1 (910) 817-7981

S5 Box

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