Adoptive Parent Intake Form

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

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.

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

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

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

Completed by:

Are you willing to travel to another state?

Budget Range

Why do you wish to adopt?

Are you willing to consider a child with special needs? If so, to what extent?

Are you open to accepting a drug-exposed child? Are you open to a birth mom who drinks alcohol? To what extent?”

Are you willing to consider a situation where the birth mother has been diagnosed with a mental illness (i.e. depression, bipolar, schizophrenia)?
Please specify what conditions you would consider if given more information:

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

How soon do you hope to complete an adoption?

After the child is placed in your home, will both parents work outside the home? If so, what are your plans for childcare?

Most of our adoption placements are semi-open placements; however, some birth mothers prefer more openness.
What is your comfort level responding to the following: phone calls, letters, pictures, updates, and visits?”

Please list any additional languages you speak:

How did you hear about our office?

Any additional notes?

Assisting Families
For More Than 30 Years

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Assisting Families For More Than 30 Years

Adoptive Parent Intake Form

Assisting Families
For More Than 30 Years