Adoptive Family Member Intake Form

Assisting Families
For More Than 30 Years

Our Practice Is Limited to Adoption & Children's Law

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Contact Information

Date:

Husband’s Legal Name

Wife’s Legal Name (Please list wife’s name as it should appear on legal documents & vital record forms)

Wife’s Maiden Name

Marriage Date

City

State

Home Address

City

State

Zip

Country

Home Phone

Fax

Who should we call first? Husband Wife

Cell (his)

Cell (hers)

Business (his)

Business (hers)

Email (his)

Please enter a valid email address.

Email (hers)

Please enter a valid email address.

Children

Name

Date of Birth

Race

Relationship

Name

Date of Birth

Race

Relationship

Name

Date of Birth

Race

Relationship

Name

Date of Birth

Race

Relationship

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

Family Information

Adoptive Father

Date of Birth

Place of Birth

Height

Weight

Hair Color

Eye Color

Number of previous marriages

Religion

Race

Last grade or degree completed

Occupation

Occupational Industry

Annual Salary

Hobbies & Interests

Adoptive Mother

Adoptive Mother

Date of Birth

Place of Birth

Height

Weight

Hair Color

Eye Color

Number of previous marriages

Religion

Race

Last grade or degree completed

Occupation

Occupational Industry

Annual Salary

Hobbies & Interests

Additional Information

Do you have a current Home Study (completed within the last 9 months)?

Completed by:

Why do you wish to adopt?

Have you read any books on adoption or attended any seminars? If so, please explain:

How soon do you hope to complete an adoption?

If you adopt a child, will both parents work outside the home? If so, what are your plans for childcare?

Please list any additional languages that you speak:

Are you willing to travel to another state?

Information of Child(ren) to be Adopted

Child 1: Full Birth Name

Date of Birth

Gender

Race

Place of Birth: Hospital Address

Hospital City

State

Zip

Country

Name as you wish it to appear on amended birth certificate:

Child 2: Full Birth Name

Date of Birth

Gender

Race

Place of Birth: Hospital Address

Hospital City

State

Zip

Country

Name as you wish it to appear on amended birth certificate:

Child 3: Full Birth Name

Date of Birth

Gender

Race

Place of Birth: Hospital Address

Hospital City

State

Zip

Country

Name as you wish it to appear on amended birth certificate:

Birth Mother Information

Birth Mother’s Legal Name

Birth Mother’s Maiden Name

Relationship to You

Phone Number

Date of Birth

Social Security Number

Race

Last Known Address

City

State

Zip

Due Date (if applicable)

Hospital

Date of Conception

Is birth mother married to birth father?
Yes No

Birth Father Information

Birth Father’s Legal Name

Relationship to You

Phone Number

Date of Birth

Social Security Number

Race

Last Known Address

City

State

Zip

Country

How did you hear about our office?

Any additional notes?

We hereby give our permission for Raymond W. Godwin, Esq. to use any photos that we send him or his office for use on his website, pamphlets, booklets, or published material. We Agree We disagree

Assisting Families
For More Than 30 Years

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Assisting Families For More Than 30 Years

Adoptive Family Member Intake Form

Assisting Families
For More Than 30 Years