Questionnaire for the Husband of Nurturing Family

The following questions are intended to provide us with an
understanding of your role in your Nurturing Family.

These questions are not intended to be in any way judgmental; we are simply gathering information
to help ensure a compatible placement of a Client within your family. With your cooperation and
assistance, the nurturing relationship can be a rewarding one for all involved.

---

	Date	/ /
A. Biographical Information
	Name           Date of Birth
	Email address:
	Race                    Religion
	Please list two references (non-family members) who have known you for over five years. Please include their names, addresses and phone numbers to facilitate our contacting them. A.
	Phone:      ()
	B.
	Phone:      ()
	Please list the fraternal, social, religious, volunteer and business organizations of which you are a member. Please provide information about your memberships and any other 'volunteer' activities in which you are involved.
	Organization or Activity	Length of Membership	Leadership Positions Recognition and Awards