Adoption Questionnaire

Date:  _____________, 2006

Please print and take the time to fill out this questionnaire as completely as possible with all of the information you have available.  Some of the information may seem redundant, but please be patient with the process and provide all of the information in the spaces allotted, as it will allow us to serve you as efficiently as possible.  Thank you.


Name of Adoptive Mother: ___________________________________________

Name of Adoptive Father:  ___________________________________________

Address:  _________________________________________________________

_________________________________________________________________

Telephone:  _______________________________________________________

Name of Child to be adopted:  _________________________________________

Birth name (if known; if unborn, write "N/A"):  __________________________

Sex:  Male ___     Female ___

Name of Birth Mother (if known):  _____________________________________

Address of Birth Mother (if known):  ___________________________________

_________________________________________________________________

Has Birth Mother consented?  YES ___    NO ___

Name of Birth Father (if known):  _____________________________________

Address of Birth Father (if known):  ___________________________________

________________________________________________________________

Has Birth Father consented?  YES ___   NO ___

DOB of Child:  _____________________________________________________

Social Security Number of Child:  _____________________________________

Will a name change be requested for the adopted child:  YES ___  NO ___

If so, the child's new requested full name:  ______________________________

DOB of Adoptive Mother:   ___________________________________________

Social Security Number of Adoptive Mother:    ___________________________

DOB of Adoptive Father:  ____________________________________________

Social Security Number of Adoptive Father:  ____________________________

DOB of Birth Mother:   ______________________________________________

Social Security Number of Birth Mother:   ______________________________

DOB of Birth Father:   ______________________________________________

Social Security Number of Birth Father:    ______________________________

Referred by:

 ____ Friend    ____ Family    ____ Minister    ____ Lawyer     ____ Social Worker

Please provide the names of any and all private adoption agencies and/or attorneys with whom you have already discussed this matter:

________________________________________________________________

________________________________________________________________

Is the child related to you?  YES ____  NO ____

If NO, what is the relationship? _______________________________________

If you had a biological child after adopting a child, how would you treat your adopted child?

_________________________________________________________________

_________________________________________________________________

If this is applicable to your situation, will you authorize the attorney to provide your names to the birth parents now or at a later date agreed to by you and the birth parents?  YES ____  NO ____

If the answer is YES, what arrangements would you agree to?  Is the child you have under consideration for adoption an orphan* (as defined below), or has the child been declared an orphan by a court or judge?  YES ____  NO ____

If YES, please provide us with written evidence (a court decree or order so stating).

*Definition of orphan under U.S. law: 

     A child, under the age of 16 at the time a petition is filed in his/her behalf to accord a classification as an immediate relative, who is an orphan because of the death or disappearance of, abandonment or desertion by, or separation or loss from, both parents, or for whom the sole or surviving parent is incapable of providing the proper care and has in writing irrevocably released the child for emigration and adoption; who has been adopted abroad by: a United States citizen and spouse jointly, or by an unmarried United States citizen at least 25 years of age, who have or has complied with the pre-adoption requirements, if any, of the child's proposed residence.

Does the child you wish to adopt currently reside in an orphanage, or what amounts to foster care for orphans, in the country in which you wish to adopt?
YES ____   NO ____

If YES, will the orphanage or foster parent charge a fee?  YES ____  NO ____

If YES, how much is the fee in U.S. dollars?  $____________

Minor Child's Birthplace:

City:  _________________________

County:   ______________________

State:  ________________________

Country:   _____________________

Child to be adopted, if born, is now in the custody of:

Name:    ________________________

Address:  _______________________

_______________________________

Telephone Number:  ______________

Custodial person's relationship to child, or name of adoption agency:  ________

________________________________________________________________

Name and addresses of ALL known immediate relatives of the child to be adopted by you (this is very important information):

Name:   __________________________________________________________

Address:  _________________________________________________________

_________________________________________________________________

Relationship:  _____________________________________________________

Name:    __________________________________________________________

Address:  _________________________________________________________

_________________________________________________________________

Relationship:  _____________________________________________________

Name:   __________________________________________________________

Address: _________________________________________________________

________________________________________________________________

Relationship: _____________________________________________________

Name:   __________________________________________________________

Address:  _________________________________________________________

_________________________________________________________________

Relationship:  _____________________________________________________

Is the child you wish to adopt related to you in some way, by birth or marriage?

YES ____  NO ____

Child is related to:  Husband ____  Wife ____  Both ____

Wife's Full Name: __________________________________________________

Adoptive Parent ____  or Natural Parent ____

Wife's Birthdate: __________________________________________________

Wife's Birthplace:  _________________________________________________

Wife's Occupation:  _________________________________________________

Number of years employed:  _____

Employer:   _______________________________________________________

Work Address:  ____________________________________________________

Telephone Numbers:  Home ___________________   Work _________________

Number of years of school (including  college):  _____

Husband's Full Name: ______________________________________________

Adoptive Parent ____ or Natural Parent ____

Husband's Birthdate:  ______________________________________________

Husband's Birthplace: ______________________________________________

Husband's Occupation:  _____________________________________________

Number of years employed: _____

Employer:  _______________________________________________________

Work Address: ____________________________________________________

Telephone Numbers:  Home _________________  Work ___________________

Number of years of school (including college): _____

Date of Marriage:  _______________

Place of Marriage:

City:  _________________________

County: _______________________

State:  ________________________

Country: ______________________

Estimated annual combined gross income:  $ ________________

Size of your residence:

Bedrooms: ______

Baths:  _________

Square Feet:  ____

Please list any previous marriages:

Husband:

Former Spouse: ______________________

Where Divorced: _____________________

Date Divorced:  ______________________

Wife:

Former Spouse: ______________________

Where Divorced: _____________________

Date Divorced:  ______________________

Please list any children now living with you:

Full Name: _________________________

Birthdate:  _________________________

Birthplace:   ________________________

City: ______________________________

County:  ___________________________

State: _____________________________

Country: ___________________________

       Natural ____ or Adopted ____

       Husband's ____  Wife's ____  Both ____

Full Name: _________________________

Birthdate:  _________________________

Birthplace:  ________________________

City:   _____________________________

County:  ___________________________

State: _____________________________

Country:  __________________________

     Natural ____ or Adopted ____

     Husband's ____  Wife's ____  Both ____

Full Name: ________________________

Birthdate:  ________________________

Birthplace: ________________________

City: _____________________________

County:  __________________________

State: ____________________________

Country: _________________________

     Natural ____ or Adopted ____

     Husband's ____  Wife's ____  Both ____