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: _____________________________________________________