DSS Foster-Adopt Intake Form

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Contact Information
Husband Wife

Children

(If more than 5, please list under additional notes section at the end of this form)

Family Information

Adoptive Father

Adoptive Mother

Additional Client Information

Information of Child(ren) to be Adopted

Birth Mother Information

Yes No
Yes No
Yes No

Birth Father Information

Yes No
Yes No
Yes No

Case Information

We Agree We disagree

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